Discharge - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions
REPC_RM400000UK07
DischargeNotification

The Discharge informs the recipient that responsibility for the service user has been transferred and contains a summary of care events and care data.

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

Indicates that this is an Encounter.

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

Indicates that this is an event.

  • Fixed value: "EVN"
[1..1] id (II)
 A unique identifier for this instance of a discharge message.

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

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

A SnomedCT code identifying the act as an Event 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.
[1..1] effectiveTime (TS)

The date the discharge report is created.

[1..1] recordTarget

A reference to the patient whose record is to contain this discharge notification.

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

Indicates the role of patient as record target.

  • Fixed value: "RCT"
[1..1] patient (Patient)

The patient whose record is to contain this discharge notification. Only new permanent NHS numbers can be used to identify patients.

[1..1] author

Refers to the person or department responsible for signing the assemblage of information in the discharge. This participation is referred to as the author of the discharge message payload.

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

Indicates that the role is the author of this discharge report..

  • 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.

  • 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 (TS)

The time of the authors participation - optional.

[1..1] role (Author)

The person or department who is the author is represented by a choice of CMETS.

[1..1] primaryInformationRecipient

Refers to the person or department who is the primary business recipient of the discharge notification.

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

Indicates the role of primary business recipient.

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

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.

  • Fixed value: "ON" - Overidding, non propagating

"ON" indicates that association overides the existing context associated with the Act, but will not propagate to any descendant Acts reached by conducting Act Relationships.

[1..1] role (PrimaryRecipient)

The person or department who is the primary recipient is represented by a choice of CMETS.

[0..1] primaryPerformer

Refers to the primary performer in the message. In the discharge this is the responsible discharging HCP.

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

Indicates the role of primary performer.

  • Fixed value: "PPRF"
[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.

  • Fixed value: "OP" - Overriding and propagating

"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] agent (UKCT_MT120301UK02)

A CMET describing an agent person known to NPfIT SDS  

[0..*] tracker

Refers to people or departments who are identified as copy recipients of the discharge. 

There can be zero, one or many copy recipients.

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

Indicates the role of copy recipient.

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

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.

  • Fixed value: "ON" - Overriding, non propagating

"ON" indicates that association overides the existing context associated with the Act, but will not propagate to any descendant Acts reached by conducting Act Relationships.

[1..1] role (CopyRecipient)

The person or department who is a copy recipient of the message.

[0..*] pertinentInformation2

Refers to the FocalActCategories pertinent to the discharge.

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

Indicates pertinent information.

  • Fixed value: "PERT"
[1..1] templateId (II)

An identifier of the Act Relationship that categorises clinical data by it"s role within the message instance.

 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.pertinentInformation2".
[1..1] pertinentFocalActCategory (FocalActCategory)

The FocalActCategory

[1..1] pertinentInformation3
Refers to the choice of clinical statements pertinent to the discharge.
[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 defaults to "true".

[1..1] templateId (II)

An identifier of the Act Relationship that categorises clinical data by it"s role within the message instance.

 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.pertinentInformation".
[1..1] pertinentAcuteCareSpell (AcuteCareSpell)

The acute care spell which is pertinent to the discharge notification.

[1..*] pertinentInformation1
Refers to the Care Record Element category which is pertinent to the Discharge.
[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }

Indicates pertinent information.

  • Fixed value: "PERT"
[1..1] templateId (II)

An identifier of the Act Relationship that categorises clinical data by the Care Record Element classification used by PSIS.

 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.pertinentInformation1".
[1..1] pertinentCareRecordElementCategory (CareRecordElementCategory)

The care record element category.

[0..1] replacementOf

Refers to a previous message this message is intended to replace

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

Indicates that the act relationship is one of replacement.

  • Fixed value: "RPLC"
[1..1] priorMessageRef (MessageRef)

The Focal Act identifier of the message being replaced.

Patient

Refers to the patient who is being discharged.

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

Indicates that the role is that of a patient.

  • Fixed value: "PAT"
[1..1] id (II)

To provide the nationally recognised identifier for the patient, the NHS number.

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

An NHS number is carried in the following way:

  • The root attribute will contain an OID with the value "2.16.840.1.113883.2.1.4.1"
  • The extension attribute will contain the NHS number.
Author
Refers to the choice of CMETS that can be used to identify the author. The author can be either a person or an organisation .
Used by: DischargeNotification
[1..1] either : UKCT_MT120501UK03

NPfIT CMET to identify an organisation fulfilling a specific role. Full details of the organisation are available from SDS. Details of the scoping organisation are either not required or available from SDS.

In this context the organisation is the department responsible for discharging the patient. This CMET should only be used if a responsible discharging HCP is not available.

             ... or ... : UKCT_MT120301UK02

NPfIT CMET to identify a person fulfilling a specific role. Full details of the person and role profile are available from SDS.

In this context the person is the responsible discharging HCP. This CMET should be used in preference to UKCT_MT120501UK03.

PrimaryRecipient

Refers to the choice of CMETS that can be used to identify the primary recipient. The recipient can be either a person or an organisation.

Used by: DischargeNotification
[1..1] either : UKCT_MT120501UK03

NPfIT CMET to identify an organisation fulfilling a specific role. Full details of the organisation are available from SDS. Details of the scoping organisation are either not required or available from SDS.

In this context the organisation is the department responsible for discharging the patient. This CMET should only be used if a responsible discharging HCP is not available.

             ... or ... : UKCT_MT120301UK02

NPfIT CMET to identify a person fulfilling a specific role. Full details of the person and role profile are available from SDS.

In this context the person is the primary recipient of the discharge. This would typically be the patient's GP. This CMET should be used in preference to UKCT_MT120501UK03.

CopyRecipient

Refers to the choice of CMETS that can be used to identify a copy recipient. A copy recipient can be either a person or an organisation.

Used by: DischargeNotification
[1..1] either : UKCT_MT120401UK03

NPfIT CMET to identify or provide detailed information about an organization fulfilling a specific role when it is not known whether the player and/or scooper details are available from SDS.

In this context the organisation is an organization who has been identified as requiring a copy of the discharge. This CMET should only be used if a specific person in the organisation does not need to be identified.

             ... or ... : UKCT_MT120201UK03

NPfIT CMET to identify or provide detailed information about a person fulfilling a specific role when it is not known whether all of the role profile, player and scooper details are available from SDS.

In this context the person is a person who has been identified as requiring a copy of the discharge. This CMET should be used in preference to UKCT_MT120401UK03 if a specific person identity is available.

FocalActCategory

A focal act category classifies the business context of a clinical statement.

Each clinical statement may be categorised by one or more headings in FocalActCategory.

Each FocalActCategory used must 'contain' at least one clinical statement. 

The category should not add any information to the statement it categorises.

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

Indicates that the class is a category.

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

Indicates that this is an event.

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

The Focal Act Category that categorises the clinical statements referenced via the relationship. 

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 coding system
  • The display text attribute will carry a description for the code from the coding system .
[1..*] component
References to the set of clinical statements classified by a specific category. 
[1..1] typeCode (CS {CNE:COMP} ){ Fixed="COMP " }

Indicates that this is a component.

  • Fixed value: "COMP"
[1..1] actRef (ActRef)

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

AcuteCareSpell
Refers to the acute care spell being ended by this discharge
Used by: DischargeNotification
[1..1] classCode (CS {CNE:ENC} ){ Fixed="ENC " }

Indicates that this is an encounter

  • Fixed value: "ENC"
[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  identifiers for this instance of a acute care spell. The first (mandatory) identifier carries the national identifier, the (optional) second a local identifier allocated by the originating 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:InteractionTypeSnCT} )

 A SnomedCT code identifying the interaction method used or to be used during this care event, e.g. face-to-face or telephone contact.

 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 AcuteCareSpell, 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 acute care spell. The start date/time is required and the end date/time is optional. 

The date range shal l 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 time and date at which the Acute Care Spell was recorded on the originating system.

[0..1] author

A link to the author

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

Indicates that the role has author responsibility.

  • 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.

  • 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 (TS)

The time of the authors participation - optional.

[1..1] role (RoleChoice)

A choice of roles played by the author

[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 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] role (ActLocation)

The choice of location.

[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 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 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.

  • 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 of the participation.

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

NPfIT CMET which allows a choice of the method of representation of the Agent.

For each participation the usage of the CMET is described below:

  • Care Event Service Provider Organisation - the CMET shall carry the SDS identifier in that uniquely identifies the organisation providing the care event.
  • Care Event HCP - the CMET shall carry the SDS identifier in of the HCP participating in the care event. There shall be at least one HCP participation and may be more than one.
  • Person participating in Care Event - the CMET shall carry either the NHS number of the person in or the name of the person in Person. name. There can be zero, one or many persons participating in a care event.
  • Procedure - the CMET shall carry the SDS identifier in of the HCP assisting the Procedure.
  • Carer - the CMET shall carry the NHS number of the carer in and the name of the carer in Person. name.
[1..1] pertinentInformation2

A link to the pertinent Care setting.

[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)

The care setting associated with the acute care spell.

[1..*] pertinentInformation4

A link to the clinical statements which are pertinent to the acute care spell.

[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 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 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 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 categorises clinical data by it's role within the message instance.

 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] pertinentClinicalStatementChoice      [CMET: UKCT_MT140901UK01]

A CMET describing the Clinical statement choice.

[0..1] pertinentInformation1

A commentary that is pertinent to the acute care spell from which the patient is being discharged.

[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 commentary that is pertinent to the acute care spell from which the patient is being discharged.

[0..*] pertinentInformation5
A link to the choice of medication CMET.
[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 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 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 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.sourceOf2"
[1..1] pertinentMedicationChoice      [CMET: UKCT_MT141001UK01]

A CMET that refers to a choice of medication information that is pertinent to a clinical statement .

[1..1] pertinentInformation

Refers to the discharge event that terminated the acute inpatient spell.

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

Indicates pertient 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 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".

[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.sourceOf2"
[1..1] pertinentDischarge (Discharge)

The discharge event being referred to.

[1..1] pertinentInformation3

Refers to the kind of service providing the acute care spell.

[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 "true".

[1..1] pertinentServiceType (ServiceType)

Refers to the service type provided during the acute care spell.

CareRecordElementCategory

A CRE category that classifies a clinical statement. 

All clinical statements shall be classified by one and only one CRE category.

 Note :- Each CRE Type can only appear once and 'contains' all the clinical statements it classifies.  A CRE Type that is present in a message instance will always classify at least one clinical statement in that message instance, i.e. if there are no statements for a particular CRE Type present in a message instance, the CRE Type concerned will not appear in that message instance.

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

Indicates that the class is a category.

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

Indicates that this is an event.

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

A SnomedCT code carrying the Care Record Element that categorises the clinical statements referenced via the relationship. 

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 .
[1..*] component

Refers to the clinical statements being classified by this Care Record Element Category.

Each clinical statement shall be categorised by one and only one CareRecordElementCategory.

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

Indicates that this is a component.

  • Fixed value: "COMP"
[1..1] actRef (ActRef)

A reference to the target clinical statement that is being linked to the Care Record Element category.

MessageRef
A reference to a previous message that this message is replacing
Used by: DischargeNotification
[1..1] classCode (CS {CNE:ENC} ){ Fixed="ENC " }

Indicates that this is encounter.

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

Indicates that this is an event.

  • Fixed value: "EVN"
[1..1] id (II)

The Focal Act identifier of the message being replaced. It is carried in an Identifier Global datatype flavour as follows:

  •  The root attribute shall contain a DCE UUID.
ActRef

Refers to a component using a unique identifier.

Used by: FocalActCategory, CareRecordElementCategory
[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.

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

The participating person 

             ... or ... : UKCT_MT120601UK02

A CMET identifying the participating device

             ... or ... : UKCT_MT120201UK03

A CMET identifying the participating agent

ActLocation
The place / organisation where the act took place.
Used by: AcuteCareSpell
[1..1] either : IncidentalLocation

The place where the activity took place.

             ... or ... : UKCT_MT120501UK03

A CMET indicating the organisation where the activity took place.

CareSetting

The care setting associated with the acute care spell.

Used by: AcuteCareSpell
[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 .
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: AcuteCareSpell
[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.

Discharge

The Discharge informs the recipient that responsibility for the service user has been transferred and contains a summary of care events and care data that took place during the care spell from which the patient is being discharge.

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

Indicates that this is an Encounter.

  • Fixed value "ENC"
[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 discharge. The first (mandatory) identifier carries the national identifier, the (optional) second a local identifier allocated by the originating 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:DischargeTypeSnCT} )

A SnomedCT code identifying the discharge 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.

 

[1..1] dischargeDispositionCode (CV {CNE:DischargeMethod} )

The method of discharge in SnomedCT coded format

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] destination
A participation indicating the destination to which the patient is being discharged. 
[1..1] typeCode (CS {CNE:DST} ){ Fixed="DST " }

The participation type

  • Fixed value: "DST" (destination)
[1..1] contextControlCode (CS {CNE:AP} ){ Fixed="AP " }

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: "AP" - Overriding and propagating

The default value of "AP" 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 (DischargeDestination)

The choice identifying a discharge destination

[0..1] pertinentInformation

The relationship to the Act providing information about any transport arrangements made as part of the discharge.

[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 defaults to "false".

[1..1] pertinentTransportInformation (TransportInformation)

The Act containing the transport arrangement information.

ServiceType
Refers to the service type that has been provided during the acute care spell
Used by: AcuteCareSpell
[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 
NonAgentRole

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

Used by: AcuteCareSpell, RoleChoice
[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: AcuteCareSpell, ActLocation, Discharge, DischargeDestination
[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

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.

DischargeDestination

The role that plays the discharge destination.

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

Details of a place that is not an SDS-recognised organisation

             ... or ... : UKCT_MT120501UK03

Details of a place that is an SDS-recognised organisation

TransportInformation

Information about the discharge destination and transport arrangements.

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

Indicates that this is an act pertaining to transport.

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

Any value from this subset of ActMood

[0..1] effectiveTime (TS)

The date and time that the transport has been arranged for.