A_RelevantHistory Tabular View

A_RelevantHistory - tabular view

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Coded With Extensions

Coded No Extensions

Information about a clinical statement that describes an observation about historic clinical information that is relevant to the patient's care.

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 this is an event.

Fixed value: "EVN"

[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:RelevantHistorySnCT} )

A SnomedCT code identifying the type of relevant history.

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

The code attribute shall contain a code from the relevant vocabulary
The code System attribute shall contain the OID for SnomedCT
The display text shall carry a description associated with the code in SnomedCT
the original text attribute may be used if required
qualifier(s) may be used if required.

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

The (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 clinically relevant date and time.

For this release the effective time shall be constrained to (IVL<TS>)

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] value (ANY)

The value of the observation.

[0..1] author

Refers to the person or department responsible for authoring the relevant history observation.

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 RelevantHistory observation. 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"

[0..1] time (TS)	When the author authorised the relevant history observation.

[0..1] modeCode (CS {CNE:ParticipationMode} )	The mode in which the author authored this relevant history . 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"

[1..1] time (IVL<TS>)	The date / time when/ during which the informant gave the information about the relevant history. 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 informant . 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 informing person.

RoleChoice

The person performing this particpation.

Used by: Observation

[1..1] either : NonAgentRole

The participating person

... or ... : UKCT_MT142101UK01

NPfIT CMET to identify the person who is participating.

The tabular view for this CMET describes its usage.

NonAgentRole

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

Used by: Observation, 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 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