| UKCT_RM144042UK01 | ||||||||||
| Diagnosis |
Details of a Diagnosis made. |
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| Used by: | ||||||||||
| [1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="OBS" } |
Indicates that this is an observation. |
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| [1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" } |
Indicates that this is an Event. |
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| [1..1] [M] code (CD {CNE:DiagnosisTypeSnCT } ) |
A SnomedCT code identifying the type of diagnosis. The Concept Descriptor (CD) dataype shall be used to carry this information as follows:
Codes from the areas defined above must be used in this CMET. |
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| [1..1] [R] effectiveTime (IVL<TS>) |
Where known the dates that the diagnosis was affective on the patient should be used i.e when the patient started with asthma and when the asthma was no longer present for the patient.
If both a start date and an end date are present the Date or Time Interval Complete data type shall be used:
If only a start date is present the Date or Time Interval After data type shall be used:
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| [1..1] [M] id (II) |
A unique identifier. The Identifier Global data type flavour is used to carry the identifier as follows:
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| [1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="normal" } |
The status of the diagnosis. The Coded Only data type flavour is used to carry this information as follows:
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| [0..1] value (ANY) |
The value of the observation. |
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| [0..1] author |
Refers to the person who is the author of the act. |
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| [1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="AUT" } |
Indicates that this is an author. |
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| [1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { 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. "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". |
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| [1..1] [R] time (TS) |
The time at which the author participated. |
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| [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 |
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| [0..1] informant |
Information about the person acting in the role of informant to the author. Note: This is only required if the Informant or Informant time is different from the inherited Informant. |
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| [1..1] [M] typeCode (CS {CNE:ParticipationType } ) { Fixed="INF" } |
Indicates that this is an informant. |
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| [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." |
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| [1..1] [R] time (TS) |
The time at which the informant participated in the diagnosis. |
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| [1..1] participant (InformantChoice) |
The person who participates in the role of author for this diagnosis.
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| [0..1] pertinentInformation |
Refers to supporting information which is pertinent to a clinical statement.
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| [1..1] [M] typeCode (CS {CNE:ActRelationshipType } ) { Fixed="PERT" } |
Indicates Pertinent Information. |
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| [1..1] [M] contextConductionInd (BL) { Fixed="true" } |
If true, associations in the parent act are conducted across the ActRelationship to the child act.
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| [1..1] [M] seperatableInd (BL) { Fixed="false" } |
Indicates that the Diagnosis and the SupportingInfo are not meant to be interpreted independently. |
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| [1..1] pertinentSupportingInfo (SupportingInfo) |
A code and/or effective time and/or text and/or value that is pertinent to the clinical statement. |
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| [0..*] pertinentInformation1 |
Information which is pertinent to the Clinical Statement |
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| [1..1] [M] typeCode (CS {CNE:ActRelationshipType } ) { Fixed="PERT" } |
Indicates Pertinent Information. |
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| [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. |
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| [1..1] [M] negationInd (BL) { Fixed="false" } |
When "true" allows the sender to specifically state that the semantic of the relationship is negated. |
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| [1..1] [M] seperatableInd (BL) { Fixed="false" } |
Indicates if the source Act is to be interpreted independently of the target Act. |
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| [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:
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| [1..1] pertinentFinding (Finding) |
Information about a clinical statement that is a finding. |
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| InformantChoice |
A choice of informants. |
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| Used by: Diagnosis | ||||||||||
| [1..1] either : NonAgentRole |
The participating person. |
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| ... or ... : UKCT_MT160018UK01 |
A CMET to identify a person on SDS or provides detailed information for a person not registered on SDS |
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| NonAgentRole |
A role played by a person who is not an agent (i.e. not a care professional). |
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| Used by: Diagnosis,InformantChoice | ||||||||||
| [1..1] [M] classCode (CS {CNE:RoleClass } ) { Fixed="ROL" } |
Indicates this is a Role. |
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| [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) datatype shall be used to carry this information as follows:
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| [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). |
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| [0..1] playingNonAgentPerson (NonAgentPerson) |
An optional link to the person playing the non-agent role. |
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| NonAgentPerson |
Details of the non-agent person. |
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| Used by: NonAgentRole | ||||||||||
| [1..1] [M] classCode (CS {CNE:EntityClass } ) { Fixed="PSN" } |
Indicates that the entity is a person. |
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| [1..1] [M] determinerCode (CS {CNE:EntityDeterminer } ) { Fixed="INSTANCE" } |
Indicates that the entity is a single identifiable person. |
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| [1..1] [M] name (SET<PN>) |
The name(s) of the person. |
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| 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. |
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| Used by: Diagnosis | ||||||||||
| [1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="OBS" } |
Indicates that this is an observation. |
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| [1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" } |
Indicates that this is an event. |
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| [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. |
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| [1..1] [M] value (ST) |
The supporting text. |
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| Finding |
Information about a clinical statement that is a finding. |
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| Used by: Diagnosis | ||||||||||
| [1..1] [M] classCode (CS {CNE:ActClass } ) { Fixed="OBS" } |
Indicates that this is an observation. |
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| [1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN" } |
Indicates that this is an event. |
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| [1..1] [M] id (II) |
The UUID of the referenced finding.
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