Finding - tabular view

No Current Link To VocabularyCoded With ExtensionsCoded No Extensions

Fri Nov 09 12:57:42 GMT 2007

COCD_TP146012UK04
Finding

Used to represent findings that do not have an specific template.

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

Indicates that this is an observation.

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

The mood code of the finding.

The Coded Only datatype flavour is used to carry this information and should be used as follows:

  • The code attribute should be set according the context of the information being conveyed and will be selected from the vocabulary.
[1..1] [M] code (CD {CNE:FindingTypeSnCT } )

A SnomedCT code taken from the subset shown.

The Concept Descriptor (CD) with CDA URL datatype/flavour shall be used to carry this information as follows:

  • The code attribute shall contain a code from the relevant vocabulary
  • The codeSystem attribute shall contain the OID for SnomedCT
  • The displayName attribute shall carry a description associated with the code in SnomedCT
  • The originalText element can be used to carry a reference element. This can link the coded item to the relevant text in the CDA section
  • qualifier (s) may be used if required
Note the implementation guidance for the domain where this template is used should be consulted regarding correct usage of the originalText element.

[1..1] [M] effectiveTime (IVL<TS>)

The clinically relevant date and time.

A 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.

If only an end date is present the Date or Time Interval Before datatype shall be used:

  • The high attribute shall contain the end date.

The center attribute may be used if the exact start / end time is not known

  • The center attribute shall contain a time stamp.
[1..1] [M] id (II)

This is a unique identifier for this instance of a finding.

The Identifier Global datatype flavour is used to carry the first identifiers follows:

  • The root attribute shall contain a DCE UUID.
[0..1] interpretationCode (CS {CNE:ObservationInterpretation } )

A code representing the interpretation of the finding.

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 ObservationInterpretation vocabulary:
[1..1] [M] statusCode (CS {CNE:ActStatus } ) { Default="completed" }

The status of the Finding.

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:
    • nullified
    • completed.
    • active
[1..1] [M] templateId (II) { Fixed="COCD_TP146012UK04#Finding" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[0..1] value (ANY)

The value associated with the Snomed concept carried in finding.code .
[0..1] author

Refers to the person or device who/which is the author of finding.

 This author is only required if the author or 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 author 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] contentId (II) { "NPFIT-000005#Role" }

This attribute, when valued in an instance, provides a unique forward pointing identifier for a template which constrains the classes and attributes which follow.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The extension attribute shall contain the template artifact Id.
[1..1] [M] functionCode (CV {CNE:AuthorFunctionType } ) { Fixed="OA" }

A code from the vocabulary shown indicating the function of the document author

The Coded Plain flavour of Coded Value (CV) datatype shall be used to carry this information as follows:

  • The code attribute shall contain the value
  • The codeSystem attribute shall contain the OID for the vocabulary concerned
  • The displayName attribute shall contain the text associated with the code
[1..1] [M] templateId (II) { Fixed="COCD_TP146012UK04#author" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] [R] time (TS)

The time at which the author authored the finding.

[1..1] participant (AuthorChoice)

A link to the choice of author templates
[0..1] informant

Refers to the person who informed the author about the finding.

This is only required if the informant is different from the inherited informant.

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

Indicates that this is an informant.

[1..1] [M] contextControlCode (CS {CNE:ContextControl } ) { Fixed="OP" }

Specifies how this informant 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] contentId (II) { "NPFIT-000002#Role" }

This attribute, when valued in an instance, provides a unique forward pointing identifier for a template which constrains the classes and attributes which follow.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The extension attribute shall contain the template artifact Id.
[1..1] [M] templateId (II) { Fixed="COCD_TP146012UK04#informant" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] participant (InformantChoice)
A link to the choice of informant.
[0..*] performer

Refers to a performer of the finding.

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

Where the author did not perform the finding 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] contentId (II) { "NPFIT-000003#Role" }

This attribute, when valued in an instance, provides a unique forward pointing identifier for a template which constrains the classes and attributes which follow.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The extension attribute shall contain the template artifact Id.
[0..1] modeCode (CS {CNE:ParticipationMode } )
The mode in which the performer participated in the finding.

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] [M] templateId (II) { Fixed="COCD_TP146012UK04#performer" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] [R] time (TS)

The time which the performer participated in the finding.

[1..1] participant (PerformerChoice)
A link to the choice of performer templates.
[0..1] referenceRange

A range of reference range values for the finding.
[1..1] [M] typeCode (CS {CNE:ActRelationshipType } ) { Fixed="REFV" }

Indicates this is a Reference Value.
[1..1] [M] templateId (II) { Fixed="COCD_TP146012UK04#referenceRange" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[1..1] referenceObservationRange (ObservationRange)

A link to the reference observation range.
AuthorChoice
Refers to the choice of authors of the finding.
Used by: Finding
[1..1] either : Template1

A link to the choice of author templates.
ObservationRange

This Act carries the Interpretation Range against which the source act was/may be interpreted. This is generally a Reference Range but may also be a Reference Change Value (RCV). Both may be carried in the same message for each appropriate observation Event.

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

Indicates that this is an observation.
[1..1] [M] moodCode (CS {CNE:ActMood } ) { Fixed="EVN.CRT" }

Indicates that this is an event criterion.
[0..1] interpretationCode (CV {CNE:ObservationInterpretation } ) { Default="N" }

The Coded Plain flavour of the Coded Value (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 codeSystem attribute shall contain the OID for the vocabulary
  • The displayName text attribute will carry a description for the code from the vocabulary

Default to 'N'. Indicates that this is a 'Normal' type value range (not a normal value)

[1..1] [M] templateId (II) { Fixed="COCD_TP146012UK04#referenceObservationRange" }

The fixed value of this attribute provides a unique identifier for the template and the classname within that template.

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

  • The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The extension attribute shall contain the fixed value.
[0..1] value (IVL<PQ>)

Carries the actual value(s) of the Interpretation range that have been used for interpretation of the Observation Event value in the source act. It should be noted that a value does not have to be present in the Source act in order to provide an interpretation of Susceptibility.

EITHER:-

The Value shall be a numerical (interval) which may have a Low and High, a Low or a High value.

Generally, interpretation ranges are nn.nn - nn.nn but in some instances, there may only be a High value( < nn.nn) or a Low value (> nn.nn)

OR:-

The Value may be a Reference Change Value (RCV) 95% probability or RCV 99% probability value as an absolute, real number with associated units or a percentage.

InformantChoice

Refers to the choice of informants of the finding.

Used by: Finding
[1..1] either : Template3

A link to the choice of templates for an informant.
PerformerChoice

Refers to the choice of performer of the finding.

Used by: Finding
[1..1] either : Template2

A link to the choice of templates for a performer.