This
page
is
part
of
the
FHIR
Specification
(v3.0.2:
STU
3).
(v3.3.0:
R4
Ballot
2).
The
current
version
which
supercedes
this
version
is
5.0.0
.
For
a
full
list
of
available
versions,
see
the
Directory
of
published
versions
.
Page
versions:
R4
R3
Vocabulary
Work
Group
|
Maturity Level : N/A | External | Use Context : Any |
This value set (http://hl7.org/fhir/ValueSet/v3-ActClass) is defined as part of HL7 v3.
Summary
| Defining URL: | http://hl7.org/fhir/ValueSet/v3-ActClass |
| Name: | v3 Code System ActClass |
| Definition: |
**** MISSING DEFINITIONS **** |
| OID: | 2.16.840.1.113883.1.11.11527 (for OID based terminology systems) |
| Source Resource | XML / JSON |
This value set is used in the following places:
This value set includes codes from the following code systems:
Terminology
http://hl7.org/fhir/v3/ActClass
This
expansion
generated
19
03
Apr
2017
2018
This
value
set
contains
119
105
concepts
Expansion
based
on
http://hl7.org/fhir/v3/ActClass
version
2016-11-11
2018-04-01
All
codes
from
system
http://hl7.org/fhir/v3/ActClass
| Lvl | Code | Display | Definition |
| 0 | ACT | act |
A
record
of
something
that
is
being
done,
has
been
done,
can
be
done,
or
is
intended
or
requested
to
be
done.
Examples:The
kinds
of
acts
that
are
common
in
health
care
are
(1)
a
clinical
observation,
(2)
an
assessment
of
health
condition
(such
as
problems
and
diagnoses),
(3)
healthcare
goals,
(4)
treatment
services
(such
as
medication,
surgery,
physical
and
psychological
therapy),
(5)
assisting,
monitoring
or
attending,
(6)
training
and
education
services
to
patients
and
their
next
of
kin,
(7)
and
notary
services
(such
as
advanced
directives
or
living
will),
(8)
editing
and
maintaining
documents,
and
many
others.
Discussion
and
Rationale:
Acts
are
the
pivot
of
the
RIM;
all
domain
information
and
processes
are
represented
primarily
in
Acts.
Any
profession
or
business,
including
healthcare,
is
primarily
constituted
of
intentional
and
occasionally
non-intentional
actions,
performed
and
recorded
by
responsible
actors.
An
Act-instance
is
a
record
of
such
an
action.
Acts
connect
to
Entities
in
their
Roles
through
Participations
and
connect
to
other
Acts
through
ActRelationships.
Participations
are
the
authors,
performers
and
other
responsible
parties
as
well
as
subjects
and
beneficiaries
(which
includes
tools
and
material
used
in
the
performance
of
the
act,
which
are
also
subjects).
The
moodCode
distinguishes
between
Acts
that
are
meant
as
factual
records,
vs.
records
of
intended
or
ordered
services,
and
the
other
modalities
in
which
act
can
appear.
One
of
the
Participations
that
all
acts
have
(at
least
implicitly)
is
a
primary
author,
who
is
responsible
of
the
Act
and
who
|
| 1 | _ActClassRecordOrganizer | record organizer | Used to group a set of acts sharing a common context. Organizer structures can nest within other context structures - such as where a document is contained within a folder, or a folder is contained within an EHR extract. |
| 2 | COMPOSITION | composition | A context representing a grouped commitment of information to the EHR. It is considered the unit of modification of the record, the unit of transmission in record extracts, and the unit of attestation by authorizing clinicians. A composition represents part of a patient record originating from a single interaction between an authenticator and the record. Unless otherwise stated all statements within a composition have the same authenticator, apply to the same patient and were recorded in a single session of use of a single application. A composition contains organizers and entries. |
| 3 | DOC | document | The notion of a document comes particularly from the paper world, where it corresponds to the contents recorded on discrete pieces of paper. In the electronic world, a document is a kind of composition that bears resemblance to their paper world counter-parts. Documents typically are meant to be human-readable. HL7's notion of document differs from that described in the W3C XML Recommendation, in which a document refers specifically to the contents that fall between the root element's start-tag and end-tag. Not all XML documents are HL7 documents. |
| 4 | DOCCLIN | clinical document | A clinical document is a documentation of clinical observations and services, with the following characteristics: Persistence - A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements; Stewardship - A clinical document is maintained by a person or organization entrusted with its care; Potential for authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; Wholeness - Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document; Human readability - A clinical document is human readable. |
| 5 | CDALVLONE | CDA Level One clinical document | A clinical document that conforms to Level One of the HL7 Clinical Document Architecture (CDA) |
| 2 | CONTAINER | record container |
Description:
Container
of
clinical
statements.
Navigational.
No
semantic
content.
Knowledge
of
the
section
code
is
not
required
to
interpret
contained
observations.
Represents
a
heading
in
a
heading
structure,
or
|
| 3 | CATEGORY | category |
A
group
of
entries
within
a
composition
or
topic
that
have
a
common
characteristic
-
for
example,
Examination,
Diagnosis,
Management
OR
Subjective,
Objective,
Analysis,
Plan.
The
distinction
from
Topic
relates
to
value
sets.
For
Category
there
is
a
bounded
list
of
things
like
|
| 3 | DOCBODY | document body | A context that distinguishes the body of a document from the document header. This is seen, for instance, in HTML documents, which have discrete <head> and <body> elements. |
| 3 | DOCSECT | document section | A context that subdivides the body of a document. Document sections are typically used for human navigation, to give a reader a clue as to the expected content. Document sections are used to organize and provide consistency to the contents of a document body. Document sections can contain document sections and can contain entries. |
| 3 | TOPIC | topic | A group of entries within a composition that are related to a common clinical theme - such as a specific disorder or problem, prevention, screening and provision of contraceptive services. A topic may contain categories and entries. |
| 2 | EXTRACT | extract | This context represents the part of a patient record conveyed in a single communication. It is drawn from a providing system for the purposes of communication to a requesting process (which might be another repository, a client application or a middleware service such as an electronic guideline engine), and supporting the faithful inclusion of the communicated data in the receiving system. An extract may be the entirety of the patient record as held by the sender or it may be a part of that record (e.g. changes since a specified date). An extract contains folders or compositions. An extract cannot contain another extract. |
| 3 | EHR | electronic health record | A context that comprises all compositions. The EHR is an extract that includes the entire chart. NOTE: In an exchange scenario, an EHR is a specialization of an extract. |
| 2 | FOLDER | folder | A context representing the high-level organization of an extract e.g. to group parts of the record by episode, care team, clinical specialty, clinical condition, or source application. Internationally, this kind of organizing structure is used variably: in some centers and systems the folder is treated as an informal compartmentalization of the overall health record; in others it might represent a significant legal portion of the EHR relating to the originating enterprise or team. A folder contains compositions. Folders may be nested within folders. |
| 2 | GROUPER | grouper |
Definition:
An
ACT
that
organizes
a
set
of
component
acts
into
a
semantic
grouping
that
share
a
particular
context
such
as
timeframe,
patient,
etc.
UsageNotes:
The
focus
in
a
GROUPER
act
is
the
grouping
of
the
contained
acts.
For
example
|
| 3 | CLUSTER | Cluster |
Description:An
ACT
that
organizes
a
set
of
component
acts
into
a
semantic
grouping
that
have
a
shared
subject.
The
subject
may
be
either
a
subject
participation
(SBJ),
subject
act
relationship
(SUBJ),
or
child
participation/act
relationship
types.
Discussion:
The
focus
in
a
CLUSTER
act
is
the
grouping
of
the
contained
acts.
For
example
|
| 1 | ACCM | accommodation | An accommodation is a service provided for a Person or other LivingSubject in which a place is provided for the subject to reside for a period of time. Commonly used to track the provision of ward, private and semi-private accommodations for a patient. |
| 1 | ACCT | account | A financial account established to track the net result of financial acts. |
| 1 | ACSN | accession | A unit of work, a grouper of work items as defined by the system performing that work. Typically some laboratory order fulfillers communicate references to accessions in their communications regarding laboratory orders. Often one or more specimens are related to an accession such that in some environments the accession number is taken as an identifier for a specimen (group). |
| 1 | ADJUD | financial adjudication | A transformation process where a requested invoice is transformed into an agreed invoice. Represents the adjudication processing of an invoice (claim). Adjudication results can be adjudicated as submitted, with adjustments or refused. Adjudication results comprise 2 components: the adjudication processing results and a restated (or adjudicated) invoice or claim |
| 1 | CACT | control act | An act representing a system action such as the change of state of another act or the initiation of a query. All control acts represent trigger events in the HL7 context. ControlActs may occur in different moods. |
| 2 | ACTN | action |
Sender
asks
addressee
to
do
something
depending
on
the
focal
Act
of
the
payload.
An
example
is
|
| 2 | INFO | information | Sender sends payload to addressee as information. Addressee does not have responsibilities beyond serving addressee's own interest (i.e., read and memorize if you see fit). This is equivalent to an FYI on a memo. |
| 2 | STC | state transition control | Description: Sender transmits a status change pertaining to the focal act of the payload. This status of the focal act is the final state of the state transition. This can be either a request or an event, according to the mood of the control act. |
| 1 | CNTRCT | contract | An agreement of obligation between two or more parties that is subject to contractual law and enforcement. |
| 2 | FCNTRCT | financial contract | A contract whose value is measured in monetary terms. |
| 3 | COV | coverage | When used in the EVN mood, this concept means with respect to a covered party: A health care insurance policy or plan that is contractually binding between two or more parties; or A health care program, usually administered by government entities, that provides coverage to persons determined eligible under the terms of the program. When used in the definition (DEF) mood, COV means potential coverage for a patient who may or may not be a covered party. The concept's meaning is fully specified by the choice of ActCoverageTypeCode (abstract) ActProgramCode or ActInsurancePolicyCode. |
| 1 | CONC | concern | Definition: A worry that tends to persist over time and has as its subject a state or process. The subject of the worry has the potential to require intervention or management. Examples: an observation result, procedure, substance administration, equipment repair status, device recall status, a health risk, a financial risk, public health risk, pregnancy, health maintenance, allergy, and acute or chronic illness. |
| 2 | HCASE | public health case |
A
public
health
case
is
a
Concern
about
an
observation
or
event
that
has
a
specific
significance
for
public
health.
The
creation
of
a
PublicHealthCase
initiates
the
tracking
of
the
object
of
concern.
The
decision
to
track
is
related
to
but
somewhat
independent
of
the
underlying
event
or
observation.
UsageNotes:
Typically
a
Public
Health
Case
involves
an
instance
or
instances
of
a
reportable
infectious
disease
or
other
condition.
The
public
health
case
can
include
a
health-related
event
concerning
a
single
individual
or
it
may
refer
to
multiple
health-related
events
that
are
occurrences
of
the
same
disease
or
condition
of
interest
to
public
health.
A
public
health
case
definition
(Act.moodCode
=
|
| 2 | OUTBR | outbreak |
An
Outbreak
is
a
concern
resulting
from
a
series
of
public
health
cases.
UsageNotes:
The
date
on
which
an
outbreak
starts
is
the
earliest
date
of
onset
among
the
cases
assigned
to
the
outbreak
and
its
ending
date
is
the
last
date
of
onset
among
the
cases
assigned
to
the
outbreak.
The
effectiveTime
attribute
is
used
to
convey
the
relevant
dates
for
the
case.
An
outbreak
definition
(Act.moodCode
=
|
| 1 | CONS | consent |
The
Consent
class
represents
informed
consents
and
all
similar
medico-legal
transactions
between
the
patient
(or
his
legal
guardian)
and
the
provider.
Examples
are
informed
consent
for
surgical
procedures,
informed
consent
for
clinical
trials,
advanced
beneficiary
notice,
against
medical
advice
decline
from
service,
release
of
information
agreement,
etc.
The
details
of
consents
vary.
Often
an
institution
has
a
number
of
different
consent
forms
for
various
purposes,
including
reminding
the
physician
about
the
topics
to
mention.
Such
forms
also
include
patient
education
material.
In
electronic
medical
record
communication,
consents
thus
are
information-generating
acts
on
their
own
and
need
to
be
managed
similar
to
medical
activities.
Thus,
Consent
is
modeled
as
a
special
class
of
Act.
The
|
| 1 | CONTREG | container registration | An Act where a container is registered either via an automated sensor, such as a barcode reader, or by manual receipt |
| 1 | CTTEVENT | clinical trial timepoint event | An identified point during a clinical trial at which one or more actions are scheduled to be performed (definition mood), or are actually performed (event mood). The actions may or may not involve an encounter between the subject and a healthcare professional. |
| 1 | DISPACT | disciplinary action | An action taken with respect to a subject Entity by a regulatory or authoritative body with supervisory capacity over that entity. The action is taken in response to behavior by the subject Entity that body finds to be undesirable. Suspension, license restrictions, monetary fine, letter of reprimand, mandated training, mandated supervision, etc.Examples: |
| 1 | EXPOS | exposure |
An
interaction
between
entities
that
provides
opportunity
for
transmission
of
a
physical,
chemical,
or
biological
agent
from
an
exposure
source
entity
to
an
exposure
target
entity.
Examples:
The
following
examples
are
provided
to
indicate
what
interactions
are
considered
exposures
rather
than
other
types
of
Acts:
A
patient
accidentally
receives
three
times
the
recommended
dose
of
their
medication
due
to
a
dosing
error.
This
is
a
substance
administration.
Public
health
and/or
safety
authorities
may
also
be
interested
in
documenting
this
with
an
associated
exposure.
A
patient
accidentally
is
dispensed
an
incorrect
medicine
(e.g.,
clomiphene
instead
of
clomipramine).
They
have
taken
several
doses
before
the
mistake
is
detected.
They
are
therefore
|
| 2 | AEXPOS | acquisition exposure | Description: An acquisition exposure act describes the proximity (location and time) through which the participating entity was potentially exposed to a physical (including energy), chemical or biological agent from another entity. The acquisition exposure act is used in conjunction with transmission exposure acts as part of an analysis technique for contact tracing. Although an exposure can be decomposed into transmission and acquisition exposures, there is no requirement that all exposures be treated in this fashion. Constraints: The Acquisition Exposure inherits the participation constraints that apply to Exposure with the following exception. The EXPSRC (exposure source) participation must never be associated with the Transmission Exposure either directly or via context conduction. |
| 2 | TEXPOS | transmission exposure | Description: A transmission exposure act describes the proximity (time and location) over which the participating source entity was capable of transmitting a physical (including energy), chemical or biological substance agent to another entity. The transmission exposure act is used in conjunction with acquisition exposure acts as part of an analysis technique for contact tracing. Although an exposure can be decomposed into transmission and acquisition exposures, there is no requirement that all exposures be treated in this fashion. Constraints: The Transmission Exposure inherits the participation constraints that apply to Exposure with the following exception. The EXPTRGT (exposure target) participation must never be associated with the Transmission Exposure either directly or via context conduction. |
| 1 | INC | incident | An event that occurred outside of the control of one or more of the parties involved. Includes the concept of an accident. |
| 1 | INFRM | inform | The act of transmitting information and understanding about a topic to a subject where the participation association must be SBJ. Discussion: This act may be used to request that a patient or provider be informed about an Act, or to indicate that a person was informed about a particular act. |
| 1 | INVE | invoice element | Represents concepts related to invoice processing in health care |
| 1 | LIST | working list | Working list collects a dynamic list of individual instances of Act via ActRelationship which reflects the need of an individual worker, team of workers, or an organization to manage lists of acts for many different clinical and administrative reasons. Examples of working lists include problem lists, goal lists, allergy lists, and to-do lists. |
| 1 | MPROT | monitoring program | An officially or unofficially instituted program to track acts of a particular type or categorization. |
| 1 | OBS | observation | Description:An act that is intended to result in new information about a subject. The main difference between Observations and other Acts is that Observations have a value attribute. The code attribute of Observation and the value attribute of Observation must be considered in combination to determine the semantics of the observation. Discussion: Structurally, many observations are name-value-pairs, where the Observation.code (inherited from Act) is the name and the Observation.value is the value of the property. Such a construct is also known as a variable (a named feature that can assume a value) hence, the Observation class is always used to hold generic name-value-pairs or variables, even though the variable valuation may not be the result of an elaborate observation method. It may be a simple answer to a question or it may be an assertion or setting of a parameter. As with all Act statements, Observation statements describe what was done, and in the case of Observations, this includes a description of what was actually observed (results or answers); and those results or answers are part of the observation and not split off into other objects. The method of action is asserted by the Observation classCode or its subclasses at the least granular level, by the Observation.code attribute value at the medium level of granularity, and by the attribute value of observation.methodCode when a finer level of granularity is required. The method in whole or in part may also appear in the attribute value of Observation.value when using coded data types to express the value of the attribute. Relevant aspects of methodology may also be restated in value when the results themselves imply or state a methodology. An observation may consist of component observations each having their own Observation.code and Observation.value. In this case, the composite observation may not have an Observation.value for itself. For instance, a white blood cell count consists of the sub-observations for the counts of the various granulocytes, lymphocytes and other normal or abnormal blood cells (e.g., blasts). The overall white blood cell count Observation itself may therefore not have a value by itself (even though it could have one, e.g., the sum total of white blood cells). Thus, as long as an Act is essentially an Act of recognizing and noting information about a subject, it is an Observation, regardless of whether it has a simple value by itself or whether it has sub-observations. Even though observations are professional acts (see Act) and as such are intentional actions, this does not require that every possible outcome of an observation be pondered in advance of it being actually made. For instance, differential white blood cell counts (WBC) rarely show blasts, but if they do, this is part of the WBC observation even though blasts might not be predefined in the structure of a normal WBC. Clinical documents commonly have Subjective and Objective findings, both of which are kinds of Observations. In addition, clinical documents commonly contain Assessments, which are also kinds of Observations. Thus, the establishment of a diagnosis is an Observation. Examples: Recording the results of a Family History Assessment Laboratory test and associated result Physical exam test and associated result Device temperature Soil lead level |
| 2 | _ActClassROI | ActClassROI |
Regions
of
Interest
(ROI)
within
a
subject
Act.
Primarily
used
for
making
secondary
observations
on
a
subset
of
a
subject
observation.
The
relationship
between
a
ROI
and
its
referenced
Act
is
specified
through
an
ActRelationship
of
type
|
| 3 | ROIBND | bounded ROI |
A
Region
of
Interest
(ROI)
specified
for
a
multidimensional
observation,
such
as
an
Observation
Series
(OBSSER).
The
ROI
is
specified
using
a
set
of
observation
criteria,
each
delineating
the
boundary
of
the
region
in
one
of
the
dimensions
in
the
multidimensional
observation.
The
relationship
between
a
ROI
and
its
referenced
Act
is
specified
through
an
ActRelationship
of
type
subject
(SUBJ),
which
must
always
be
present.
Each
of
the
boundary
criteria
observations
is
connected
with
the
ROI
using
ActRelationships
of
type
|
| 3 | ROIOVL | overlay ROI |
A
Region
of
Interest
(ROI)
specified
for
an
image
using
an
overlay
shape.
Typically
used
to
make
reference
to
specific
regions
in
images,
e.g.,
to
specify
the
location
of
a
radiologic
finding
in
an
image
or
to
specify
the
site
of
a
physical
finding
by
|
| 2 | _SubjectPhysicalPosition | subject physical position | The spatial relationship of a subject whether human, other animal, or plant, to a frame of reference such as gravity or a collection device. |
|
|
ALRT | detected issue | An observation identifying a potential adverse outcome as a result of an Act or combination of Acts. Examples: Detection of a drug-drug interaction; Identification of a late-submission for an invoice; Requesting discharge for a patient who does not meet hospital-defined discharge criteria. Discussion: This class is commonly used for identifying 'business rule' or 'process' problems that may result in a refusal to carry out a particular request. In some circumstances it may be possible to 'bypass' a problem by modifying the request to acknowledge the issue and/or by providing some form of mitigation. Constraints: the Act or Acts that may cause the the adverse outcome are the target of a subject ActRelationship. The subbtypes of this concept indicate the type of problem being detected (e.g. drug-drug interaction) while the Observation.value is used to repesent a specific problem code (e.g. specific drug-drug interaction id). |
| 2 | BATTERY | battery | Definition: An observation that is composed of a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are run together because of automation. A battery can define required and optional component observations and, in some cases, will define complex rules that determine whether or not a particular observation is made. BATTERY is a constraint on the Observation class in that it is understood to always be composed of component observations. UsageNotes: The focus in a BATTERY is that it is composed of individual observations. In request (RQO) mood, a battery is a request to perform the component observations. In event (EVN) mood a battery is a reporting of associated set of observation events. In definition mood a battery is the definition of the associated set of observations. Examples: Vital signs, Full blood count, Chemistry panel. |
| 2 | CLNTRL | clinical trial | The set of actions that define an experiment to assess the effectiveness and/or safety of a biopharmaceutical product (food, drug, device, etc.). In definition mood, this set of actions is often embodied in a clinical trial protocol; in event mood, this designates the aggregate act of applying the actions to one or more subjects. |
|
|
DGIMG | diagnostic image | Class for holding attributes unique to diagnostic images. |
| 2 | GEN | genomic observation | Description:An observation of genomic phenomena. |
| 3 | DETPOL | determinant peptide | Description:A determinant peptide in a polypeptide as described by polypeptide. |
| 3 | EXP | expression level | Description:An expression level of genes/proteins or other expressed genomic entities. |
| 3 | LOC | locus | Description:The position of a gene (or other significant sequence) on the genome. |
| 3 | PHN | phenotype | Description:A genomic phenomenon that is expressed externally in the organism. |
| 3 | POL | polypeptide | Description:A polypeptide resulting from the translation of a gene. |
| 3 | SEQ | bio sequence | Description:A sequence of biomolecule like the DNA, RNA, protein and the like. |
| 3 | SEQVAR | bio sequence variation | Description:A variation in a sequence as described by BioSequence. |
| 2 | INVSTG | investigation | An formalized inquiry into the circumstances surrounding a particular unplanned event or potential event for the purposes of identifying possible causes and contributing factors for the event. This investigation could be conducted at a local institutional level or at the level of a local or national government. |
| 2 | OBSSER | observation series |
Container
for
Correlated
Observation
Sequences
sharing
a
common
frame
of
reference.
All
Observations
of
the
same
cd
must
be
comparable
and
relative
to
the
common
frame
of
reference.
For
example,
a
3-channel
ECG
device
records
a
12-lead
ECG
in
4
steps
(3
leads
at
a
time).
Each
of
the
separate
3-channel
recordings
would
be
in
their
own
|
| 3 | OBSCOR | correlated observation sequences | Container for Observation Sequences (Observations whose values are contained in LIST<>'s) having values correlated with each other. Each contained Observation Sequence LIST<> must be the same length. Values in the LIST<>'s are correlated based on index. E.g. the values in position 2 in all the LIST<>'s are correlated. This is analogous to a table where each column is an Observation Sequence with a LIST<> of values, and each row in the table is a correlation between the columns. For example, a 12-lead ECG would contain 13 sequences: one sequence for time, and a sequence for each of the 12 leads. |
| 2 | POS | position | An observation denoting the physical location of a person or thing based on a reference coordinate system. |
| 3 | POSACC | position accuracy | Description:An observation representing the degree to which the assignment of the spatial coordinates, based on a matching algorithm by a geocoding engine against a reference spatial database, matches true or accepted values. |
| 3 | POSCOORD | position coordinate | Description:An observation representing one of a set of numerical values used to determine the position of a place. The name of the coordinate value is determined by the reference coordinate system. |
| 2 | SPCOBS | specimen observation | An observation on a specimen in a laboratory environment that may affect processing, analysis or result interpretation |
| 2 | VERIF | Verification | An act which describes the process whereby a 'verifying party' validates either the existence of the Role attested to by some Credential or the actual Vetting act and its details. |
| 1 | PCPR | care provision | An Act that of taking on whole or partial responsibility for, or attention to, safety and well-being of a subject of care. Discussion: A care provision event may exist without any other care actions taking place. For example, when a patient is assigned to the care of a particular health professional. In request (RQO) mood care provision communicates a referral, which is a request: from one party (linked as a participant of type author (AUT)), to another party (linked as a participant of type performer (PRF), to take responsibility for a scope specified by the code attribute, for an entity (linked as a participant of type subject (SBJ)). The scope of the care for which responsibility is taken is identified by code attribute. In event (EVN) mood care provision indicates the effective time interval of a specified scope of responsibility by a performer (PRF) or set of performers (PRF) for a subject (SBJ). Examples: Referral from GP to a specialist. Assignment of a patient or group of patients to the case list of a health professional. Assignment of inpatients to the care of particular nurses for a working shift. |
| 2 | ENC | encounter | An interaction between a patient and healthcare participant(s) for the purpose of providing patient service(s) or assessing the health status of a patient. For example, outpatient visit to multiple departments, home health support (including physical therapy), inpatient hospital stay, emergency room visit, field visit (e.g., traffic accident), office visit, occupational therapy, telephone call. |
| 1 | POLICY | policy | Description:A mandate, regulation, obligation, requirement, rule, or expectation unilaterally imposed by one party on: The activity of another party The behavior of another party The manner in which an act is executed |
| 2 | JURISPOL | jurisdictional policy | Description:A mandate, regulation, obligation, requirement, rule, or expectation unilaterally imposed by a jurisdiction on: The activity of another party The behavior of another party The manner in which an act is executed Examples:A jurisdictional mandate regarding the prescribing and dispensing of a particular medication. A jurisdictional privacy or security regulation dictating the manner in which personal health information is disclosed. A jurisdictional requirement that certain services or health conditions are reported to a monitoring program, e.g., immunizations, methadone treatment, or cancer registries. |
| 2 | ORGPOL | organizational policy | Description:A mandate, obligation, requirement, rule, or expectation unilaterally imposed by an organization on: The activity of another party The behavior of another party The manner in which an act is executed Examples:A clinical or research protocols imposed by a payer, a malpractice insurer, or an institution to which a provider must adhere. A mandate imposed by a denominational institution for a provider to provide or withhold certain information from the patient about treatment options. |
| 2 | SCOPOL | scope of practice policy | Description:An ethical or clinical obligation, requirement, rule, or expectation imposed or strongly encouraged by organizations that oversee particular clinical domains or provider certification which define the boundaries within which a provider may practice and which may have legal basis or ramifications on: The activity of another party The behavior of another party The manner in which an act is executed Examples:An ethical obligation for a provider to fully inform a patient about all treatment options. An ethical obligation for a provider not to disclose personal health information that meets certain criteria, e.g., where disclosure might result in harm to the patient or another person. The set of health care services which a provider is credentialed or privileged to provide. |
| 2 | STDPOL | standard of practice policy | Description:A requirement, rule, or expectation typically documented as guidelines, protocols, or formularies imposed or strongly encouraged by an organization that oversees or has authority over the practices within a domain, and which may have legal basis or ramifications on: The activity of another party The behavior of another party The manner in which an act is executed Examples:A payer may require a prescribing provider to adhere to formulary guidelines. An institution may adopt clinical guidelines and protocols and implement these within its electronic health record and decision support systems. |
| 1 | PROC | procedure | An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. Examples: : Procedures may involve the disruption of some body surface (e.g. an incision in a surgical procedure), but they also include conservative procedures such as reduction of a luxated join, chiropractic treatment, massage, balneotherapy, acupuncture, shiatsu, etc. Outside of clinical medicine, procedures may be such things as alteration of environments (e.g. straightening rivers, draining swamps, building dams) or the repair or change of machinery etc. |
| 2 | SBADM | substance administration | The act of introducing or otherwise applying a substance to the subject. Discussion: The effect of the substance is typically established on a biochemical basis, however, that is not a requirement. For example, radiotherapy can largely be described in the same way, especially if it is a systemic therapy such as radio-iodine. This class also includes the application of chemical treatments to an area. Examples: Chemotherapy protocol; Drug prescription; Vaccination record |
| 2 | SBEXT | Substance Extraction | Description: The act of removing a substance from the subject. |
| 3 | SPECCOLLECT | Specimen Collection | A procedure for obtaining a specimen from a source entity. |
| 1 | REG | registration | Represents the act of maintaining information about the registration of its associated registered subject. The subject can be either an Act or a Role, and includes subjects such as lab exam definitions, drug protocol definitions, prescriptions, persons, patients, practitioners, and equipment. The registration may have a unique identifier - separate from the unique identification of the subject - as well as a core set of related participations and act relationships that characterize the registration event and aid in the disposition of the subject information by a receiving system. |
| 1 | REV | review |
The
act
of
examining
and
evaluating
the
subject,
usually
another
act.
For
example,
|
| 1 | SPCTRT | specimen treatment | A procedure or treatment performed on a specimen to prepare it for analysis |
| 1 | SPLY | supply |
Supply
orders
and
deliveries
are
simple
Acts
that
focus
on
the
delivered
product.
The
product
is
associated
with
the
Supply
Act
via
|
|
|
STORE | storage |
The
act
of
putting
something
away
for
safe
keeping.
The
|
| 1 | SUBST | Substitution |
Definition:
Indicates
that
the
subject
Act
has
undergone
or
should
undergo
substitution
of
a
type
indicated
by
Act.code.
Rationale:
Used
to
specify
|
| 1 | TRFR | transfer | Definition: The act of transferring information without the intent of imparting understanding about a topic to the subject that is the recipient or holder of the transferred information where the participation association must be RCV or HLD. |
| 1 | TRNS | transportation | Transportation is the moving of a payload (people or material) from a location of origin to a destination location. Thus, any transport service has the three target instances of type payload, origin, and destination, besides the targets that are generally used for any service (i.e., performer, device, etc.) |
| 1 | XACT | financial transaction |
A
sub-class
of
Act
representing
any
transaction
between
two
accounts
whose
value
is
measured
in
monetary
terms.
In
the
|
| 1 | _ActClassContainer | ActClassContainer | ActClassContainer |
| 2 | ENTRY | entry | This context represents the information acquired and recorded for an observation, a clinical statement such as a portion of the patient's history or an inference or assertion, or an action that might be intended or has actually been performed. This class may represent both the actual data describing the observation, inference, or action, and optionally the details supporting the clinical reasoning process such as a reference to an electronic guideline, decision support system, or other knowledge reference. |
| 2 | ORGANIZER | organizer |
Organizer
of
entries.
Navigational.
No
semantic
content.
Knowledge
of
the
section
code
is
not
required
to
interpret
contained
observations.
Represents
a
heading
in
a
heading
structure,
or
|
| 0 | DOCCNTNT | ||
| 0 | DOCLIST | ||
| 0 | DOCLSTITM | ||
| 0 | DOCPARA | ||
| 0 | DOCTBL | ||
| 0 | LINKHTML | ||
| 0 | LOCALATTR | ||
| 0 | LOCALMRKP | ||
| 0 | ordered | ||
| 0 | REFR | ||
| 0 | TBLCOL | ||
| 0 | TBLCOLGP | ||
| 0 | TBLDATA | ||
| 0 | TBLHDR | ||
| 0 | TBLROW | ||
| 0 | tbody | ||
| 0 | tfoot | ||
| 0 | thead | ||
| 0 | unordered |
®©
HL7.org
2011+.
FHIR
Release
3
(STU;
v3.0.2-11200)
Mixed
Nomative/Trial
Use
Ballot
(v3.3.0-13671)
generated
on
Thurs,
Oct
24,
2019
11:53+1100.
Tue,
Apr
3,
2018
12:20+1000.
QA
Page
Links:
Search
|
Version
History
|
Table
of
Contents
|
Credits
|
Compare
to
DSTU2
DSTU3
|
|
Propose
a
change