A_Documentation - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions
UKCT_RM144035UK01
DocumentChoice

The choice of document type.
Used by:
[1..1] either : CareProfessionalDocumentation

Documentation exchanged between Care Professionals for specific formal purposes.
             ... or ... : ThirdPartyCorrespondence
Exchange of documentation between Care Professionals and third party organisations.
             ... or ... : PatientCarerCorrespondence

Exchange of documentation between Care Professionals and patients or their representatives.
CareProfessionalDocumentation

Documentation exchanged between Care Professionals for specific formal purposes.

Used by: DocumentChoice
[1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="DOC" }

Indicates that this in a documentation act.
[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }

Indicates that this in an event.
[1..1] [M] code (CD {CNE:DocumentTypeSnCT } )

A SNOMED CT code taken from the vocabulary shown.

The Concept Descriptor (CD) data type 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 displaytext 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.

The use of the SNOMED CT terms in this subset are for guidance purposes only. Codes outside this subset may be used at clinical discretion. There will be codes in the subset which are unsuitable.

The content of this subset will change in response to user requirements.
[1..1] [R] effectiveTime (TS)

The date and time that the document was finalised or attested by the author..
[1..1] [M] id (II)

A unique identifier.

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

  • The root attribute shall contain a DCE UUID.
[1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="active" }

The status of the Documentation.

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

  • The code attribute will contain a one of the following codes from the Act Status vocabulary:
    • nullified;
    • active.
[1..1] [M] text (ED)

The body text of the documentation.
[0..1] title (ST)

The title of the documentation.
[0..1] versionNumber (INT)

The version number of the documentation.
[0..*] author

Refers to the person who is the author of the act.

Constraint: This author is only required if the author or author time is different from the inherited author.


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

Indicates that this is an author.

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

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.

"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] [M] time (TS)

The time at which the author participated.

This will be the same as effective time.

[1..1] role      [CMET: UKCT_MT160018UK01]

A CMET to identify a person on SDS or provides detailed information for a person not registered on SDS.
ThirdPartyCorrespondence

Exchange of documentation between Care Professionals and third party organisations.

Used by: DocumentChoice
[1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="DOC" }
Indicates this is a documentation act.
[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }

Indicates that this in an event.
[1..1] [M] code (CD {CNE:DocumentTypeSnCT } )


A SnomedCT code taken from the subset DocumentTypeSnCT.

The datatype must be constrained to CD and used as indicated below.

The Concept Descriptor (CD) datatype 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 displaytext 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 time at which the document was released.
[1..1] [M] id (II)

A unique identifier.

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

  • The root attribute shall contain a DCE UUID.
[1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="active" }
The status of the Documentation.

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

  • The code attribute will contain a one of the following codes from the Act Status vocabulary:
    • nullified;
    • active;
[1..1] [M] text (ED)

The body text of the correspondence.
[0..1] title (ST)

The title of the correspondence.
[0..1] versionNumber (INT)

The version number of the correspondence.
[0..1] author

Refers to the person who is the author of the act.

Constraint: This author is only required if the author or author time is different from the inherited author.


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

Indicates that this is an author.

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

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.

"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] [R] time (TS)

The time at/during which the author participated.

[1..1] participant (AuthorChoice)

The person who participates in the role of author.

That is the author of the document

AuthorChoice

The choice of author of the document.
Used by: ThirdPartyCorrespondence
[1..1] either : UKCT_MT160018UK01

A CMET to identify a person on SDS or provides detailed information for a person not registered on SDS.
             ... or ... : NonAgentRole
A person who is not an agent (i.e. not a car e professional).
NonAgentRole

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

Used by: PatientCarerCorrespondence
[1..1] [M] classCode (CS {CNE:RoleClass } ) { Fixed="ROL" }

Indicates that this is a role.
[1..1] [M] 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) data type 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] 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).

[0..1] playingNonAgentPerson (NonAgentPerson)

A link to the person playing the non-agent role.

NonAgentPerson

Details of the non-agent person (i.e. not a care professional).

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

Indicates this is a person.

[1..1] [M] determinerCode (CS {CNE:EntityDeterminer } ) { Fixed="INSTANCE" }

Indicates that the entity is a single identifiable person.

[1..1] [M] name (SET<PN>)

The name(s) of the person.

PatientCarerCorrespondence

Exchange of documentation between Care Professionals and patients or their representatives.

Used by: DocumentChoice
[1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="DOC" }
Indicates that this in a Documentation act.
[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }

Indicates that this in an event.
[1..1] [M] code (CD {CNE:DocumentTypeSnCT } )

A SNOMED CT code taken from the vocabulary shown.

The Concept Descriptor (CD) data type 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 displaytext 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] [R] effectiveTime (TS)

The time at which the document was released.
[1..1] [M] id (II)

A unique identifier.

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

  • The root attribute shall contain a DCE UUID.
[1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="active" }

The status of the Document.

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

  • The code attribute will contain a one of the following codes from the Act Status vocabulary:
    • nullified
    • active
[1..1] [M] text (ED)

The body text of the correspondence.
[0..1] title (ST)

The title of the correspondence.
[0..1] versionNumber (INT)

The version number of the correspondence.
[0..1] author

Refers to the person who is the author of the act.

Constraint: This author is only required if the author or author time is different from the inherited author.


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

Indicates that this is an author.

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

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.

"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] [R] time (TS)

The time at/during which the author participated.

[1..1] nonAgentRole (NonAgentRole)

The person who participates in the role of author.