A_PresentingComplaint - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions
UKCT_RM144002UK01
Observation
The observation represents a Presenting Complaint.  This details headline information collected at Triage, including information such as 'RTA', 'Assault' ot 'Major Incident'.
Used by:
[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 set of unique identifiers for this instance of a presenting complaint 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:PresentingComplaintSnCT} )

A SnomedCT code identifying the type of presenting complaint.

 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 Observation, e.g. active, suspended, completed.

Shall be present if status is aborted or cancelled.

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 presenting complaint.

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] value (ANY)

The value of the observation.

[0..1] author

Refers to the person or device responsible for authoring the Presenting Complaint. 

Only required if author is different to author inherited via context conduction

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

Indicates the role of author of this Presenting Complaint.

  • 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.

  • Fixed value: "OP" - Overriding and propagating

"O" (Overriding) - the association replaces any context of the same or more specific type that has been conducted from the parent act.

"P" (Propagating) - the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true"

[1..1] time (TS)

When the author authorised the information contained in the Presenting Complaint observation.

[0..1] modeCode (CS {CNE:ParticipationMode} )

The mode in which the participant participated in the presenting complaint.

Required if not "ELECTRONIC" 

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 ParticipationMode vocabulary.
[1..1] role (RoleChoice)

The person performing this particpation.

[0..1] informant
Refers to the person or device acting in the role of informant.  The patient may act as an informant.

Only required if informant is different to informant inherited via context conduction  

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

Indicates that the role is that of informant.

  • Fixed value: "INF"
[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

"O" (Overriding) - the association replaces any context of the same or more specific type that has been conducted from the parent act.

"P" (Propagating) - the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true"

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

[1..1] time (TS)

The date / time when/ during which  the informant gave the information about the presenting complaint.

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.

[0..1] modeCode (CS {CNE:ParticipationMode} )

The mode in which the participant participated in the observation about a presenting complaint.

Required if not "ELECTRONIC" 

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 ParticipationMode vocabulary.
[1..1] role (RoleChoice)

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

[0..1] pertinentInformation4

Refers to supporting information which is pertinent to a clinical statement.  

[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 is fixed at "true".

[1..1] seperatableInd (BL)

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

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

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

[1..1] pertinentSupportingInfo (SupportingInfo)

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

RoleChoice

The person performing this particpation.

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

The participating person 

             ... or ... : UKCT_MT120601UK02

A CMET identifying the participating device.

AgentDevice.classCode shall carry a fixed value of  "AGNT"

AgentDevice. id  shall carry a nationally agreed identifier for the role being played.  This shall be a code from a national coding scheme.

A national code is carried in the following way:

  • The root attribute shall contain the OID that identifies the coding scheme
  • The extension attribute shall contain the code

If the device can be identified by reference to SDS then

DeviceSDS.classcode shall carry a fixed value of "DEV" to indicates that this is a Device. In this context the device can be hardware or software.

DeviceSDS.determinerCode shall carry a fixed value of "INSTANCE"

DeviceSDS.id shall carry an SDS identifier that uniquely identifies the Device.

This is carried in the following way.

  • The root attribute shall contain an OID with the appropriate value 
  • The extension attribute shall contain the SDS Device ID

If the device cannot be identified by reference to SDS then

Device.classCode shall carry a fixed value of  "DEV"

Device.determinerCode shall carry a fixed value fof "INSTANCE"

Device.id  shall carry an optional identifier that uniquely identifies the Device.   This shall be a code from a national scheme.

A national code is carried in the following way:

  • The root attribute shall carry the OID that identifies the coding scheme
  • The extension attribute shall contain the code

If an id is not present, then a name shall be included .

Device.code shall carry an optional code to describe the type of device.

If a code is not present, then a desc shall be included.

Device.name shall carry an optional  name of the device.

This shall be included if an id is not present.

Device.desc shall carry an optional description of the type of device.

This shall be included if a code is not present.

Device.manufacturerModelName shall optionally carry the model name as allocated by the Device manufacturer.

Device.softwareName shall optionally carry the name of the software used by the Device.

If the device is scoped by an organization then and the organizaton can be identified by reference to SDS then

OrganizationSDS.classCode shall carry a fixed value of  "ORG"

OrganizationSDS.determinerCode shall carry a fixed value of "INSTANCE".

OrganizationSDS.id shall carry an SDS identifier that uniquely identifies the Organization.This is carried in the following way:

  • The root attribute shall contain an OID with the value 1.2.826.0.1285.0.1.10
  • The extension attribute shall contain the SDS Organization ID

If the device is scoped by an organization then and the organizaton cannot be identified by reference to SDS then

Organization.classCode shall carry a fixed value of  "ORG"

Organization.determinerCode shall carry a fixed value of "INSTANCE"

Organization.id shall carry an optional identifier that uniquely identifies the Organization.This shall be a code from a national scheme.

A national code is carried in the following way:

  • the root attribute shall contain the OID that identifies the coding scheme
  • the extension attribute shall contain the code

If an id is not present, then a name shall be included.

Organization.code shall optionally carry a value from the OrganizationType vocabualary  to identfy the type of Organization.

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

  • The code attribute shall contain a value from the list of codes in the OrganizationType vocabulary.

If a code is not present, then a desc shall be included.

Organization.name shall optionally contain the name of the Organization. This shall be included if an id is not present.

Organization.desc shall contain a optional description of the type of Organization. This shall be included if a code is not present.

Organization.telecom shall contain optional  telephone contact details for the Organization.

Organization.addr shall contain an optional address of the Organization

             ... or ... : UKCT_MT142101UK01

NPfIT CMET to identify the person who is participating.

The tabular view for this CMET describes its usage.

Used by: Observation
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: Observation
[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"
[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.

NonAgentRole

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

Used by: Observation, RoleChoice, Observation
[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 an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number).

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

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

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

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

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

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..1] name (SET<PN>)

The name(s) of the person