Vocabulary for EhrCompoundCode
Description
The value here shall be taken from one of four vocabularies, depending upon the value of the EhrCompoundLevel attribute of the CompoundStatement.
1 Topic Vocabulary
Where the EhrCompoundLevel attribute value is ‘topic’ the vocabulary is used to name distinct clinical topics (e.g. problems) dealt with in a single encounter or composition.
Values:
Version: | 02 |
Date: | 5th April 2004 |
Code | Description | Note |
A code taken from one of: · Clinical Terms (Read Codes) v3 · The Read Codes Version 2 · The Read Codes Four Byte Set
| The composition describes a topic within a consultation record or composition. | E.g. information about aspects of a patient’s diabetes.
A code from Snomed-CT (UK) or Clinical Terms (Read codes) Version 3 may be accompanied by additional qualifying codes from the same coding system. |
Optionally, a code from another of the coding systems described above, representing a "translation" of the first code. A translation code is not required if the data was originally recorded in Snomed-CT UK | The “translation” code should have an identical or more general meaning than the original code. |
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2 Category Vocabulary
Where the EhrCompoundLevel attribute value is ‘category’, the vocabulary is used to name sections of an encounter record or composition, such as the history of the presenting complaint provided by the patient.
Values:
Version: | 02 |
Date: | 28th November 2003 |
Code | Description | Note |
9b0p. | Template |
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9c0.. | Record heading |
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9c00. | Action plan (community) |
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9c01. | Examination |
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9c02. | Health administration |
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9c03. | Heath needs (community) |
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9c04. | History |
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9c05. | Intervention |
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9c06. | Management |
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9c07. | Patient medication advice |
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9c08. | Presenting complaint |
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9c09. | Procedure codes (community) |
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9c0A. | Protocol entry |
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9c0B. | Referral |
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9c0C. | Result |
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9c0D. | Symptom |
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90cF. | Test request |
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9c0G. | Values (community) |
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9c0H. | Follow-up |
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9c0Y. | Other | The original Text element specifies some other category. |
3 Cluster Vocabulary
Where the EhrCompoundLevel attribute value is ‘cluster’, the vocabulary is used to name subdivisions that group together a logically connected set of observations and circumstances applicable to those observations.
Values:
Version: | 02 |
Date: | 28th November 2003 |
Code | Description | Note |
A code taken from one of: · Clinical Terms (Read Codes) v3, · The Read Codes Version 2 · The Read Codes Four Byte Set | A code representing the name of a cluster of statements | E.g. a series of full blood counts
A code from Snomed-CT (UK) or Clinical Terms (Read codes) Version 3 may be accompanied by additional qualifying codes from the same coding system. |
Optionally, a code from another of the coding systems described above, representing a "translation" of the first code. A translation code is not required if the data was originally recorded in Snomed-CT UK | The “translation” code should have an identical or more general meaning than the original code. |
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4 Battery Vocabulary
Where the EhrCompoundLevel attribute value is ‘battery’, the vocabulary is used to specify the name of a set of observations from an identifiable investigation (e.g. Blood Pressure, Full Blood Count, Electrolytes and Urea).
Values:
Version: | 02 |
Date: | 28th November 2003 |
Code | Description | Note |
A code taken from one of: · Clinical Terms (Read Codes) v3 · The Read Codes Version 2 · The Read Codes Four Byte Set | A code representing the name of a battery of observations.
| E.g. the name of a specific kind of investigation, e.g. a blood pressure observation or full blood count.
A code from Snomed-CT (UK) or Clinical Terms (Read codes) Version 3 may be accompanied by additional qualifying codes from the same coding system. |
Optionally, a code from another of the coding systems described above, representing a "translation". A translation code is notrequired if the data was originally recorded in Snomed-CT UK | The “translation” code should have an identical or more general meaning than the original code. |
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