Contents

 

Change History   

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1    Template Definitions for NPfIT Roles

1.1    AuthorSDS - COCD_TP145001UK03

Template to represent a role of assigned author details of which are available on SDS

 

               

1.2    AuthorNonSDSWithOrgNonSDS - COCD_TP145002UK03

Template to represent a role of assigned author details of which are not available on SDS with an optional scoping non SDS organization.

 

               

1.3    AuthorNonSDSWithOrgSDS - COCD_TP145003UK03

Template to represent an assigned entity role where details are not available on SDS but the scoping organization is.

 

               

1.4    EntitySDS - COCD_TP145004UK03

Template to represent an assigned entity role where the details are available on SDS

 

               

1.5    EntityNonSDSWithOrgSDS - COCD_TP145005UK03

Template to represent an assigned entity role where the details are not available on SDS but details of the scoping organization are. 

 

               

1.6    EntityNonSDSWithOrgNonSDS - COCD_TP145006UK03

Template to represent a role where neither the assigned entity role nor the scoping organization are available on SDS

 

               

1.7    RelatedEntity - COCD_TP145007UK03

Template to represent a related person

 

               

1.8    ServiceDeliveryLocationSDS - COCD_TP145008UK03

Template to represent a role of service delivery location

 

               

1.9    AuthorDeviceSDS - COCD_TP145009UK03

Template to represent a role of a device where the details of which are available from SDS

 

               

1.10    DeviceNonSDSWithOrgSDS - COCD_TP145010UK03

Template to represent a role of a device where neither the details of which are not available from SDS nor the scoping organization

 

               

1.11    NonNamedPersonWithOrgSDS - COCD_TP145012UK03

Template to represent a role of an person where the actual name of the person  is not required and the scoping organization's details are available on SDS.

 

               

1.12    NonNamedPersonWithOrgNonSDS - COCD_TP145013UK03

Template to represent a role of an person where the actual name of the person  is not required and the scoping organization's details are not available on SDS.

 

               

1.13    IncidentalLocation - COCD_TP145014UK03

Template to represent a role of incidental location

 

               

1.14    RequesterEntity - COCD_TP145016UK03

Template to represent a role requester to seal an item of information.

 

               

1.15    RecipientOrganization - COCD_TP145017UK03

Template to represent recipient organization.

 

               

 

1.16    CustodianOrganization - COCD_TP145018UK03

Template to represent custodian organization.

 

               

 

1.17    NonNamedPersonAuthorSDS - COCD_TP145019UK03

Template to represent author when only organization is stated.

 

               

 

1.18    Patient - COCD_TP145020UK03

Template to represent a patient.

 

               

 

1.19    RecipientEntitySDS - COCD_TP145021UK02

Template to represent an recipient assigned entity role where the details are available on SDS

 

               

 

1.20    EntitySDSwithRequiredRoleProfileId - COCD_TP145022UK01

Template to represent an assigned entity role where the details are available on SDS but the persons role profile id may not be available on the source system and therefore cannot be included.

 

               

 

1.21    Accessor - COCD_TP145023UK01

Template to represent the role of an Accessor.

 

               

 

 

1.22    HealthCareFacility - COCD_TP145024UK01

Template to represent the Healthcare facility where the encompassing encounter took place or is associated with.

 

               

 

2    Template Definitions for NPfIT CDA coded entries

2.1    LifeStyle - COCD_TP146001UK04

Template to allow the representation of the patient's lifestyle

 

               

2.2    Smoking - COCD_TP146002UK04

Template to represent observations relating to the patient with regards to smoking

 

               

2.3    AlcoholIntake - COCD_TP146003UK04

Template to represent observations relating to the patient with regards to alcohol

 

               

2.4    SocialOrPersonalCircumstance - COCD_TP146004UK04

Template to represent the patient's social or personal circumstances

 

               

2.5    CareEvent - COCD_TP146005UK04

Template to represent care events

 

               

2.6    Problem - COCD_TP146006UK04

Template used with a reference to a clinical statement to indicate that the clinical statement has been highlighted as a problem

 

               

2.7    LinkAssertion - COCD_TP146007UK04

Template used to assert a link between 2 clinical statements

 

               

Note:
Suppliers are not required to implement Link Assertion for systems deployed against Spine Release 2008A. This is because the limited     requirement to code information for that release (only Medications and Allergies & Adverse Drug Reactions) means that the environment does not support a clear Business Use Case for Link Assertion. However, it should be assumed that this will change as the level of coded information increases.

2.8    ProblemMemberAssertion - COCD_TP146008UK04

Template used to assert that a clinical statement is a member of a problem

 

               

2.9    ProblemLinkAssertion - COCD_TP146009UK04

Template used to assert a link between 2 problems

 

               

2.10    RiskToPerson - COCD_TP146010UK04

Template used to highlight a clinical statement as a risk to a clinician or third party

 

               

2.11    Diagnosis - COCD_TP146011UK04

Template for diagnoses

 

                   

2.12    Finding - COCD_TP146012UK04

Template for non organized findings that do not have a specific template

 

               

2.13    BloodPressure - COCD_TP146013UK04

Template for representation of blood pressure observations

 

               

2.14    Weight - COCD_TP146014UK04

Template for representation of weight observations

 

               

2.15    Height - COCD_TP146015UK04

Template for representation of height observations

 

               

2.16    Temperature - COCD_TP146016UK04

Template for representation of temperature observations

 

               

2.17    OrganizedFinding - COCD_TP146017UK04

Template for representation of organized findings such as a battery of tests

 

               

2.18    FamilyHistory - COCD_TP146018UK04

Template for the representation of family history

 

               

2.19    Investigation - COCD_TP146019UK04

Template for the representation of investigative procedures

 

               

2.20    PersonalPreference - COCD_TP146020UK04

Template for personal preferences of the patient

 

               

2.21    Service - COCD_TP146021UK04

Template to represent services and providers of the service to the patient

 

               

2.22    AllergicOrAdverseReactionEvent - COCD_TP146022UK04

Template to represent allergy and adverse reaction events

 

               

Severe Adverse Reaction to Fluoxetine

Adverse Reaction to Fluoxetine

Adverse Reaction to Cefataxime

Drug-induced Anaphylaxis to Succinylcholine

Drug-induced Anaphylactoid Reaction to Atracurium

2.23    ProvisionOfAdviceAndInformation - COCD_TP146023UK04

Template to represent advice or information given to a patient or the patient's representative

 

               

2.24    AdministrativeProcedure - COCD_TP146024UK04

Template to represent an administrative procedure

 

               

2.25    AllergyPropensity - COCD_TP146025UK04

Template to represent a propensity to an allergy or adverse reaction

 

               

Severe Allergy to Fluoxetine

Drug Allergy to Enalapril

Drug Allergy to Succinylcholine

Drug Allergy to Ibuprofen

2.26    RiskToPatient - COCD_TP146026UK04

Template to represent an identified risk to a patient

 

               

2.27    Treatment - COCD_TP146027UK04

Template to represent treatment given to the patient

 

               

2.28    MedicationAdministrationDose - COCD_TP146029UK04

Template to represent administration of a single dosage of medication

 

               

2.29    MedicationAdministrationCourse - COCD_TP146030UK04

Template to represent administration of a course of medication

 

               

2.30    PlanMedicationAdministration - COCD_TP146031UK04

A template to represent a plan to administer medication

 

               

2.31    RequestMedicationSupply - COCD_TP146032UK04

Template to represent a request to supply medication

 

               

2.32    SupplyMedication - COCD_TP146033UK04

Template to represent a supply of medication

 

               

2.33    RequestMedicationAdministration - COCD_TP146034UK04

Template to represent a request for medication administration

 

               

2.34    MedicationDiscontinuation - COCD_TP146036UK04

Template for the act of discontinuation of medication

 

               

2.35    PatientMovement - COCD_TP146037UK04

Template for represent transportation of the patient including the origin and destination of patient

 

               

2.36    Discharge - COCD_TP146038UK04

Template for the act of the discharge from an inpatient stay

 

               

2.37    NullifyDocument - COCD_TP146049UK05

Template to carry the meta data required to nullify a document.

 

               

 

2.38    EncompassingEncounter - COCD_TP146060UK01

 Template to represent the place and location of an encompassing encounter of a care event.

 

               

 

2.39    TextSection - COCD_TP146061UK01

 Template to constrain the text sections used in the NPfIT CDA implementation

 

               

 

2.40    CRETypeList - COCD_TP146062UK01

 Template to carry a list of ids categorised by a CRE as used in the NPfIT CDA implementation

 

               

 

 

 

3    Template Definitions for NPfIT CDA coded entries associated with sealing

3.1    SealingEvent - COCD_TP146043UK05

Template to carry the meta data associated with a sealing event.

 

               

 

3.2    RefusalToSeal - COCD_TP146044UK05

Template to carry the meta data associated with a refusal to seal.

 

               

 

3.3    UnSealingEvent - COCD_TP146045UK05

Template to carry the meta data associated with a Unsealing event.

 

               

 

4    Template Definitions for reference validation

These templates are machine generated and are used to constrain relationships between templates.

4.1    LifeStyleRef - COCD_TP147001UK03

 Template to constrain a lifestyle act reference

 

               

4.2    SmokingRef - COCD_TP147002UK03

Template to constrain a smoking act reference

 

               

4.3    AlcoholIntakeRef - COCD_TP147003UK03

Template to constrain an alcohol intake reference

 

               

4.4    SocialOrPersonalCircumstanceRef - COCD_TP147004UK03

Template to constrain a social or personal circumstance act reference

 

               

4.5    CareEventRef - COCD_TP147005UK03

Template to constrain a care event act reference

 

               

4.6    ProblemRef - COCD_TP147006UK03

Template to constrain a problem reference

 

               

4.7    RiskToPersonRef - COCD_TP147010UK03

Template to constrain a risk to person act reference

 

               

4.8    DiagnosisRef - COCD_TP147011UK03

Template to constrain a diagnosis act reference

 

               

4.9    FindingRef - COCD_TP147012UK03

Template to constrain a finding act reference

 

               

4.10    BloodPressureRef - COCD_TP147013UK03

Template to constrain a blood pressure act reference

 

               

4.11    WeightRef - COCD_TP147014UK03

Template to constrain a weight act reference

 

               

4.12    HeightRef - COCD_TP147015UK03

Template to constrain a height act reference

 

               

4.13    TemperatureRef - COCD_TP147016UK03

Template to constrain a temperature act reference

 

               

4.14    FindingOrganizerRef - COCD_TP147017UK03

Template used to constrain a finding organizer act reference

 

               

4.15    FamilyHistoryRef - COCD_TP147018UK03

Template used to constrain a family history act reference

 

               

4.16    InvestigationRef - COCD_TP147019UK03

Template used to constrain an investigation act reference

 

               

4.17    PersonalPreferenceRef - COCD_TP147020UK03

Template used to constrain a person preference act reference

 

               

4.18    ServiceRef - COCD_TP147021UK03

Template used to constrain a service act reference

 

               

4.19    AllergicOrAdverseReactionEventRef - COCD_TP147022UK03

Template used to constrain an allergy diagnosis event act reference

 

               

4.20    ProvisionOfAdviceAndInformationRef - COCD_TP147023UK03

Template used to constrain a provision of advice and information act reference

 

                

4.21    AdministrativeProcedureRef - COCD_TP147024UK03

Template used to constrain an administrative procedure act reference

 

               

4.22    AllergyPropensityRef - COCD_TP147025UK03

Template used to constrain a allergy act reference

 

               

4.23    RiskToPatientRef - COCD_TP147026UK03

Template used to constrain risk to patient act reference

 

               

4.24    TreatmentRef - COCD_TP147027UK03

Template used to constrain a treatment act reference

 

               

4.25    MedicationAdministrationDoseRef - COCD_TP147029UK04

Template used to constrain a medication administration dose act reference

 

               

4.26    MedicationAdministrationCourseRef - COCD_TP147030UK04

Template used to constrain a medication administration course act reference

 

               

4.27    PlanMedicationAdministrationRef - COCD_TP147031UK04

Template used to constrain a plan medication administration act reference

 

               

4.28    RequestMedicationSupplyRef - COCD_TP147032UK03

Template used to constrain a request medication supply act reference

 

               

4.29    SupplyMedicationRef - COCD_TP147033UK03

Template used to constrain a supply medication act reference

 

               

4.30    RequestMedicationAdministrationRef - COCD_TP147034UK03

Template used to constrain a request medication administration act reference

 

               

4.31    MedicationDiscontinuationRef - COCD_TP147036UK03

Template used to constrain an investigation act reference

 

               

4.32    PatientMovementRef - COCD_TP147037UK03

Template used to constrain a patient movement act reference

 

               

4.33    DischargeRef - COCD_TP147038UK03

Template used to constrain a discharge act reference