A_CareEvent - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions
UKCT_RM144037UK01
CareEvent

To be used to represent a Care Event.

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

Indicates that the care event is an encounter.
[1..1] [M] 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..1] [M] code (CD {CNE:EncounterSnCT } )

A SnomedCT code identifying the encounter type.

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

  • The code attribute shall contain acode from the relevant vocabulary
  • The code System attribute shall containthe 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.

951000000133

Encounter type

The codes in this subset must always be used in this encounter act.
[1..1] [R] 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.
[1..1] [M] id (II)

This is a unique identifier for this instance of a Care Event.

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

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

The status of the Care Event.

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:
    • normal
    • nullified
    • active
    • completed.
[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 which the author participated.

[1..1] participant (RoleChoice)

The device or person who participates in the role of author.

[0..1] location

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

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

Indicates that this is a location.
[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] participant (ActLocationChoice)

The participation relationship to the choice of location.
[1..1] [M] location1

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

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

Indicates that this is a location.
[1..1] [M] contextControlCode (CS {CNE:ParticipationContextControl } ) { 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] dedicatedServiceDeliveryLocation (DedicatedServiceDeliveryLocation)

A link to the care setting which is the service delivery location.

[0..*] participant

Refers to participants in clinical events not specifically modelled.

[1..1] [M] 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.

The current allowed participation types are : -

  • Data entry person - "ENT"
  • Responsible party - "RESP" -
  • Secondary performer - "SPRF" - used for assisting care professional
  • Remote - "RML"
  • Destination - "DST"
  • Consultant - "CON"
  • Referrer - "REF"
  • Receiver - "RCV"
  • Witness - "WIT"
  • Baby - "BBY"
  • Donor - "DON"
  • Origin - "ORG"
  • Verifier - "VRF"
  • Authenticator - "AUTHEN"
  • Legal authenticator - "LA"
  • Admitter - "ADM"
  • Attender - "ATND"
[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] modeCode (CS {CNE:ParticipationMode } )

The mode in which the participant participated in the act described by the clinical statement.

The Coded Only data type 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] [R] time (IVL<TS>)

The time of the participation.
[1..1] participant (ParticipantChoice)

A choice on an organisation or person participant.
[0..*] performer

Refers to a performer of the act.

Where performer participation is used, then all performers must be stated, even if they authored the act.

Where the author did not perform the act then the performer(s) should be explicitly stated.
[1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="PRF" }

Indicates that this is a performer.
[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] modeCode (CS {CNE:ParticipationMode } )

The mode in which the informant gave the information about the Care Event.

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] [R] time (IVL<TS>)

The time during / at which the performer participated in the act described by the clinical statement.
[1..1] participant (RoleChoice)

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

[0..1] pertinentInformation
Refers to supporting information which is pertinent to a clinical statement.
[1..1] [M] typeCode (CS {CNE:ActRelationshipType } ) { Fixed="PERT" }

Indicates pertinent information..
[1..1] [M] contextConductionInd (BL) { Fixed="true" }
If true, associations in the parent act are conducted across the ActRelationship to the child act.
[1..1] [M] seperatableInd (BL) { Fixed="false" }
Indicates if the source Act is to be interpreted independently of the target Act.
[1..1] pertinentSupportingInfo (SupportingInfo)

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

[0..*] pertinentInformation1

Information which is pertinent to the Clinical Statement.

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

Indicates Pertinent Information.
[1..1] [M] inversionInd (BL) { Fixed="false" }

An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed.

[1..1] [M] negationInd (BL) { Fixed="false" }

When "true" allows the sender to specifically state that the semantic of the relationship is negated.

[1..1] [M] seperatableInd (BL) { Fixed="true" }

Indicates if the source Act is to be interpreted independently of the target Act.

[1..1] [M] templateId (II) { Fixed="CSAB_RM-NPfITUK10.sourceOf1" }

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

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

  • The root attribute shall containthe 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] pertinentReferencedClinicalStatementChoice (ReferencedClinicalStatementChoice)
A choice of clinical statement reference.
RoleChoice

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

Used by: CareEvent
[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 ... : UKCT_MT120601UK02

A CMET identifying the participating device.

AgentDevcie.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 of "INSTANCE"

Device.id shall carry an optional identifier that uniquely identifies the Device. Thisshall bea 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 codeto describe the type of device.

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

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

This shall be included if an id is not present.

Device.descshall 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 organization 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 organization 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.idshall carryan optional identifier that uniquely identifies the Organization. Thisshall bea 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 vocabulary to identify 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 description 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 containa 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 ... : NonAgentRole

The participating person who is a non-agent (not a clinician).
NonAgentRole

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

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

Indicates 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 CodedValue (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 containthe 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 either an OID for the identification scheme and the identifier within that scheme (e.g. for patient NHS number).

[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] [M] classCode (CS {CNE:EntityClass } ) { Fixed="PSN" }

Indicates that the entity 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.
ActLocationChoice

A choice of location relevant to the clinical statement.

Used by: CareEvent
[1..1] either : UKCT_MT160017UK01

A CMET to identify an organisation on SDS or provides detailed information for an organisation not registered on SDS.
             ... or ... : IncidentalLocation

The place where the activity took place.
IncidentalLocation
A role played by a location that is not an organisational site.
Used by: CareEvent,ActLocationChoice
[1..1] [M] classCode (CS {CNE:RoleClass } ) { Fixed="ISDLOC" }

Indicates that the role is a incidental location.
[1..1] [R] 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 CodedValue (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.

This is currently not represented by a subset but by a list of codes..

[0..1] location (Place)

Details of the individual place playing the role of the IncidentialLocation.
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 SHALL be used.

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

Indicates that the entity is a place.
[1..1] [M] determinerCode (CS {CNE:EntityDeterminer } ) { Fixed="INSTANCE" }

Indicates that the entity is a single identifiable place.
[0..1] addr (AD)

An optional address of the place.
[0..1] gpsText (ST)

An optional GPS reference. It may be as precise as required.
[0..1] [R] name (TN)

The optional name of the place.
[0..1] positionText (ED)

An optional grid reference. It may be as precise as required.
[0..1] telecom (TEL)

An optional telecom contact for the place.
DedicatedServiceDeliveryLocation

The type of location where the service was / is to be delivered.

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

Indicates that this is a dedicated service delivery location.
[1..1] [M] code (CV {CNE:CareSettingTypeSnCT } )

A SnomedCT code specifying the care setting..

The Coded Plain flavour of the CodedValue (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 containthe OID for SnomedCT;
  • The display text attribute will carry a description for the code from the coding system.
This is currently not represented by a subset but by a list of codes..
ParticipantChoice
A choice on an organisation or person participant.
Used by: CareEvent
[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 ... : UKCT_MT160017UK01

A CMET to identify an organisation on SDS or provides detailed information for an organisation not registered on SDS.
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: CareEvent
[1..1] [M] classCode (CS {CNE:ActClass } ) { 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.

[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" }

Indicates this is an event.
[1..1] [M] code (CV {CNE:TextType } ) { Fixed="SupportingText" }

A code from the vocabulary shown indicating type of text.

The Coded Plain flavour of the Coded Value (CV) data type shall be used to carry this information.
[1..1] [M] value (ST)
The Supporting Info text
ReferencedClinicalStatementChoice

A choice of clinical statement reference.
Used by: CareEvent
[1..1] either : PersonalPreference

Reference to PersonalPreference
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Finding

Reference to Finding
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Problem

Reference to Problem
[1..1] [M] classCode ( CS{CNE : CNOD} ) ){ Fixed = "CNOD"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : SocialContext

Reference to SocialContext
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : FamilyHistory

Reference to FamilyHistory
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Diagnosis

Reference to Diagnosis
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Investigation

Reference to Investigation
[1..1] [M] classCode ( CS{CNE : PROC} ) ){ Fixed = "PROC"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : x_ActMoodIntentEvent})

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Medication

Reference to Medication
[1..1] [M] classCode ( CS{CNE : SBADM} ) ){ Fixed = "SBADM"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : RQO} ){ Fixed = "RQO"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : MedicationAdministration

Reference to MedicationAdministration
[1..1] [M] classCode ( CS{CNE : SBADM} ) ){ Fixed = "SBADM"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Document

Reference to Document
[1..1] [M] classCode ( CS{CNE : DOC} ) ){ Fixed = "DOC"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : RiskToPerson

Reference to RiskToPerson
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : AllergiesAndAdverseReactionsDE

Reference to AllergiesAndAdverseReactionsDE
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : AdministrativeProcedure

Reference to AdministrativeProcedure
[1..1] [M] classCode ( CS{CNE : ACT} ) ){ Fixed = "ACT"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : x_ActMoodIntentEvent})

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : RiskToPatient

Reference to RiskToPatient
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Service

Reference to Service
[1..1] [M] classCode ( CS{CNE : PCPR} ) ){ Fixed = "PCPR"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : x_ActMoodIntentEvent})

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : ProvisionOfAdviceAndInformation

Reference to ProvisionOfAdviceAndInformation
[1..1] [M] classCode ( CS{CNE : INFRM} ) ){ Fixed = "INFRM"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : Treatment

Reference to Treatment
[1..1] [M] classCode ( CS{CNE : PROC} ) ){ Fixed = "PROC"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : x_ActMoodIntentEvent})

TemplateText
[1..1] [M] id ( II )

TemplateText
             ... or ... : AllergiesAndAdverseReactionsIdent

Reference to AllergiesAndAdverseReactionsIdent
[1..1] [M] classCode ( CS{CNE : OBS} ) ){ Fixed = "OBS"}

TemplateText
[1..1] [M] moodCode ( CS{CNE : EVN} ){ Fixed = "EVN"}

TemplateText
[1..1] [M] id ( II )

TemplateText