Vocabulary for CREType

 

Description:

Assigned OID:           2.16.840.1.113883.2.1.3.2.4.17.56

A categorisation of patient Care Record elements. Taken from NPfIT Care Record Elements document, v1.1

This has now been deprecated in favour of CRETypeSnCT

 

 

Values:

Version:

01

Date:

10th May 2004

 

Code

Description

Note

010

Personal demographics

 

020

Personal Preference 

 

021

Proactive Personal Preference 

 

022

Reactive Personal Preference 

 

030 

Finding

 

031

Clinical Observation

 

032

Investigation Result

 

040

Diagnosis

 

050

Family History

 

060

Social Context

 

061

Social & Personal Circumstances

 

062

Services and Carers

 

063

Behaviour

 

100

Procedures

 

101

Treatment

 

102

Investigation

 

103

Administrative Procedure

 

104

Provision of Advice and Information to Patients and Carers

 

110

Medication

 

150

Care Event

 

160

Additional Record Location

 

170

Clinical Correspondence

 

171

Clinical Documentation

 

172

Patient/Carer Correspondence

 

173

Third-party Correspondence

 

200

Functioning and Wellbeing

 

210

Projected and actual outcomes

 

211

Prognosis

 

212

Goal

 

213

Actual Outcome

 

220

Problems & Issues

 

230

Risks and Warnings

 

231

Allergies & Adverse Reactions

 

232

Risk to Patient

 

233

Risk to Care Practitioner or Third Party

 

240

Care Plan