|
Level
|
Code
|
Display
|
Definition
|
|
1
|
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
"owns"
"owns"
the
act.
Responsibility
for
the
act
means
responsibility
for
what
is
being
stated
in
the
Act
and
as
what
it
is
stated.
Ownership
of
the
act
is
assumed
in
the
sense
of
who
may
operationally
modify
the
same
act.
Ownership
and
responsibility
of
the
Act
is
not
the
same
as
ownership
or
responsibility
of
what
the
Act-object
refers
to
in
the
real
world.
The
same
real
world
activity
can
be
described
by
two
people,
each
being
the
author
of
their
Act,
describing
the
same
real
world
activity.
Yet
one
can
be
a
witness
while
the
other
can
be
a
principal
performer.
The
performer
has
responsibilities
for
the
physical
actions;
the
witness
only
has
responsibility
for
making
a
true
statement
to
the
best
of
his
or
her
ability.
The
two
Act-instances
may
even
disagree,
but
because
each
is
properly
attributed
to
its
author,
such
disagreements
can
exist
side
by
side
and
left
to
arbitration
by
a
recipient
of
these
Act-instances.
In
this
sense,
an
Act-instance
represents
a
"statement"
"statement"
according
to
Rector
and
Nowlan
(1991)
[Foundations
for
an
electronic
medical
record.
Methods
Inf
Med.
30.]
Rector
and
Nowlan
have
emphasized
the
importance
of
understanding
the
medical
record
not
as
a
collection
of
facts,
but
"a
"a
faithful
record
of
what
clinicians
have
heard,
seen,
thought,
and
done."
done."
Rector
and
Nowlan
go
on
saying
that
"the
"the
other
requirements
for
a
medical
record,
e.g.,
that
it
be
attributable
and
permanent,
follow
naturally
from
this
view."
view."
Indeed
the
Act
class
is
this
attributable
statement,
and
the
rules
of
updating
acts
(discussed
in
the
state-transition
model,
see
Act.statusCode)
versus
generating
new
Act-instances
are
designed
according
to
this
principle
of
permanent
attributable
statements.
Rector
and
Nolan
focus
on
the
electronic
medical
record
as
a
collection
of
statements,
while
attributed
statements,
these
are
still
mostly
factual
statements.
However,
the
Act
class
goes
beyond
this
limitation
to
attributed
factual
statements,
representing
what
is
known
as
"speech-acts"
"speech-acts"
in
linguistics
and
philosophy.
The
notion
of
speech-act
includes
that
there
is
pragmatic
meaning
in
language
utterances,
aside
from
just
factual
statements;
and
that
these
utterances
interact
with
the
real
world
to
change
the
state
of
affairs,
even
directly
cause
physical
activities
to
happen.
For
example,
an
order
is
a
speech
act
that
(provided
it
is
issued
adequately)
will
cause
the
ordered
action
to
be
physically
performed.
The
speech
act
theory
has
culminated
in
the
seminal
work
by
Austin
(1962)
[How
to
do
things
with
words.
Oxford
University
Press].
An
activity
in
the
real
world
may
progress
from
defined,
through
planned
and
ordered
to
executed,
which
is
represented
as
the
mood
of
the
Act.
Even
though
one
might
think
of
a
single
activity
as
progressing
from
planned
to
executed,
this
progression
is
reflected
by
multiple
Act-instances,
each
having
one
and
only
one
mood
that
will
not
change
along
the
Act-instance
life
cycle.
This
is
because
the
attribution
and
content
of
speech
acts
along
this
progression
of
an
activity
may
be
different,
and
it
is
often
critical
that
a
permanent
and
faithful
record
be
maintained
of
this
progression.
The
specification
of
orders
or
promises
or
plans
must
not
be
overwritten
by
the
specification
of
what
was
actually
done,
so
as
to
allow
comparing
actions
with
their
earlier
specifications.
Act-instances
that
describe
this
progression
of
the
same
real
world
activity
are
linked
through
the
ActRelationships
(of
the
relationship
category
"sequel").
"sequel").
Act
as
statements
or
speech-acts
are
the
only
representation
of
real
world
facts
or
processes
in
the
HL7
RIM.
The
truth
about
the
real
world
is
constructed
through
a
combination
(and
arbitration)
of
such
attributed
statements
only,
and
there
is
no
class
in
the
RIM
whose
objects
represent
"objective
"objective
state
of
affairs"
affairs"
or
"real
processes"
"real
processes"
independent
from
attributed
statements.
As
such,
there
is
no
distinction
between
an
activity
and
its
documentation.
Every
Act
includes
both
to
varying
degrees.
For
example,
a
factual
statement
made
about
recent
(but
past)
activities,
authored
(and
signed)
by
the
performer
of
such
activities,
is
commonly
known
as
a
procedure
report
or
original
documentation
(e.g.,
surgical
procedure
report,
clinic
note
etc.).
Conversely,
a
status
update
on
an
activity
that
is
presently
in
progress,
authored
by
the
performer
(or
a
close
observer)
is
considered
to
capture
that
activity
(and
is
later
superceded
by
a
full
procedure
report).
However,
both
status
update
and
procedure
report
are
acts
of
the
same
kind,
only
distinguished
by
mood
and
state
(see
statusCode)
and
completeness
of
the
information.
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2
|
(_ActClassRecordOrganizer)
Abstract
|
|
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.
|
|
3
|
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.
|
|
4
|
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.
|
|
5
|
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.
|
|
6
|
CDALVLONE
|
CDA
Level
One
clinical
document
|
A
clinical
document
that
conforms
to
Level
One
of
the
HL7
Clinical
Document
Architecture
(CDA)
|
|
3
|
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
"container
tree".
"container
tree".
The
record
entries
relating
to
a
single
clinical
session
are
usually
grouped
under
headings
that
represent
phases
of
the
encounter,
or
assist
with
layout
and
navigation.
Clinical
headings
usually
reflect
the
clinical
workflow
during
a
care
session,
and
might
also
reflect
the
main
author's
reasoning
processes.
Much
research
has
demonstrated
that
headings
are
used
differently
by
different
professional
groups
and
specialties,
and
that
headings
are
not
used
consistently
enough
to
support
safe
automatic
processing
of
the
E
H
R.
|
|
4
|
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
"Examination",
"Diagnosis"
"Examination",
"Diagnosis"
or
SOAP
categories.
For
Topic
the
list
is
wide
open
to
any
clinical
condition
or
reason
for
a
part
of
an
encounter.
A
CATEGORY
MAY
CONTAIN
ENTRIES.
|
|
4
|
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.
|
|
4
|
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.
|
|
4
|
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.
|
|
3
|
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.
|
|
4
|
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.
|
|
3
|
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.
|
|
3
|
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
"a
"a
request
to
group"
group"
(RQO),
"a
"a
type
of
grouping
that
is
allowed
to
occur"
occur"
(DEF),
etc.
Unlike
WorkingList,
which
represents
a
dynamic,
shared,
continuously
updated
collection
to
provide
a
"view"
"view"
of
a
set
of
objects,
GROUPER
collections
tend
to
be
static
and
simply
indicate
a
shared
set
of
semantics.
Note
that
sharing
of
semantics
can
be
achieved
using
ACT
as
well.
However,
with
GROUPER,
the
sole
semantic
is
of
grouping.
|
|
4
|
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
"a
"a
request
to
cluster"
cluster"
(RQO),
"a
"a
type
of
cluster
that
is
allowed
to
occur"
occur"
(DEF),
etc.
Examples:
Radiologic
investigations
that
might
include
administration
of
a
dye,
followed
by
radiographic
observations;
"Isolate
cluster"
"Isolate
cluster"
which
includes
all
testing
and
specimen
processing
performed
on
a
specific
isolate;
a
set
of
actions
to
perform
at
a
particular
stage
in
a
clinical
trial.
|
|
2
|
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.
|
|
2
|
ACCT
|
account
|
A
financial
account
established
to
track
the
net
result
of
financial
acts.
|
|
2
|
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).
|
|
2
|
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
|
|
2
|
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.
|
|
3
|
ACTN
|
action
|
Sender
asks
addressee
to
do
something
depending
on
the
focal
Act
of
the
payload.
An
example
is
"fulfill
"fulfill
this
order".
order".
Addressee
has
responsibilities
to
either
reject
the
message
or
to
act
on
it
in
an
appropriate
way
(specified
by
the
specific
receiver
responsibilities
for
the
interaction).
|
|
3
|
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.
|
|
3
|
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.
|
|
2
|
CNTRCT
|
contract
|
An
agreement
of
obligation
between
two
or
more
parties
that
is
subject
to
contractual
law
and
enforcement.
|
|
3
|
FCNTRCT
|
financial
contract
|
A
contract
whose
value
is
measured
in
monetary
terms.
|
|
4
|
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.
|
|
2
|
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.
|
|
3
|
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
=
"definition")
"definition")
includes
the
description
of
the
clinical,
laboratory,
and
epidemiologic
indicators
associated
with
a
disease
or
condition
of
interest
to
public
health.
There
are
case
definitions
for
conditions
that
are
reportable,
as
well
as
for
those
that
are
not.
A
public
health
case
definition
is
a
construct
used
by
public
health
for
the
purpose
of
counting
cases,
and
should
not
be
used
as
clinical
indications
for
treatment.
Examples
include
AIDS,
toxic-shock
syndrome,
and
salmonellosis
and
their
associated
indicators
that
are
used
to
define
a
case.
|
|
3
|
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
=
"definition"
"definition"
includes
the
criteria
for
the
number,
types
and
occurrence
pattern
of
cases
necessary
to
declare
an
outbreak
and
to
judge
the
severity
of
an
outbreak.
|
|
2
|
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
"signatures"
"signatures"
to
the
consent
document
are
represented
electronically
through
Participation
instances
to
the
consent
object.
Typically
an
informed
consent
has
Participation.typeCode
of
"performer",
"performer",
the
healthcare
provider
informing
the
patient,
and
"consenter",
"consenter",
the
patient
or
legal
guardian.
Some
consent
may
associate
a
witness
or
a
notary
public
(e.g.,
living
wills,
advanced
directives).
In
consents
where
a
healthcare
provider
is
not
required
(e.g.
living
will),
the
performer
may
be
the
patient
himself
or
a
notary
public.
Some
consent
has
a
minimum
required
delay
between
the
consent
and
the
service,
so
as
to
allow
the
patient
to
rethink
his
decisions.
This
minimum
delay
can
be
expressed
in
the
act
definition
by
the
ActRelationship.pauseQuantity
attribute
that
delays
the
service
until
the
pause
time
has
elapsed
after
the
consent
has
been
completed.
|
|
2
|
CONTREG
|
container
registration
|
An
Act
where
a
container
is
registered
either
via
an
automated
sensor,
such
as
a
barcode
reader,
or
by
manual
receipt
|
|
2
|
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.
|
|
2
|
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:
|
|
2
|
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
"exposed"
"exposed"
to
a
medicine
that
there
was
no
therapeutic
indication
for
them
to
receive.
There
are
several
substance
administrations
in
this
example.
Public
health
and/or
safety
authorities
may
also
be
interested
in
documenting
this
with
associated
exposures.
In
a
busy
medical
ward,
a
patient
is
receiving
chemotherapy
for
a
lymphoma.
Unfortunately,
the
IV
infusion
bag
containing
the
medicine
splits,
spraying
cytotoxic
medication
over
the
patient
being
treated
and
the
patient
in
the
adjacent
bed.
There
are
three
substance
administrations
in
this
example.
The
first
is
the
intended
one
(IV
infusion)
with
its
associated
(implicit)
exposure.
There
is
an
incident
with
an
associated
substance
administration
to
the
same
patient
involving
the
medication
sprayed
over
the
patient
as
well
as
an
associated
exposure.
Additionally,
the
incident
includes
a
substance
administration
involving
the
spraying
of
medication
on
the
adjacent
patient,
also
with
an
associated
exposure.
A
patient
who
is
a
refugee
from
a
war-torn
African
nation
arrives
in
a
busy
inner
city
A&E
department
suffering
from
a
cough
with
bloody
sputum.
Not
understanding
the
registration
and
triage
process,
they
sit
in
the
waiting
room
for
several
hours
before
it
is
noticed
that
they
have
not
booked
in.
As
soon
as
they
are
being
processed,
it
is
suspected
that
they
are
suffering
from
TB.
Vulnerable
(immunosuppressed)
patients
who
were
sharing
the
waiting
room
with
this
patient
may
have
been
exposed
to
the
tubercule
bacillus,
and
must
be
traced
for
investigation.
This
is
an
exposure
(or
possibly
multiple
exposures)
in
the
waiting
room
involving
the
refugee
and
everyone
else
in
the
waiting
room
during
the
period.
There
might
also
be
a
number
of
known
or
presumed
substance
administrations
(coughing)
via
several
possible
routes.
The
substance
administrations
are
only
hypotheses
until
confirmed
by
further
testing.
A
patient
who
has
received
an
elective
total
hip
replacement
procedure
suffers
a
prolonged
stay
in
hospital,
due
to
contracting
an
MRSA
infection
in
the
surgical
wound
site
after
the
surgery.
This
is
an
exposure
to
MRSA.
Although
there
was
some
sort
of
substance
administration,
it's
possible
the
exact
mechanism
for
introduction
of
the
MRSA
into
the
wound
will
not
be
identified.
Routine
maintenance
of
the
X-ray
machines
at
a
local
hospital
reveals
a
serious
breach
of
the
shielding
on
one
of
the
machines.
Patients
who
have
undergone
investigations
using
that
machine
in
the
last
month
are
likely
to
have
been
exposed
to
significantly
higher
doses
of
X-rays
than
was
intended,
and
must
be
tracked
for
possible
adverse
effects.
There
has
been
an
exposure
of
each
patient
who
used
the
machine
in
the
past
30
days.
Some
patients
may
have
had
substance
administrations.
A
new
member
of
staff
is
employed
in
the
laundry
processing
room
of
a
small
cottage
hospital,
and
a
misreading
of
the
instructions
for
adding
detergents
results
in
fifty
times
the
usual
concentration
of
cleaning
materials
being
added
to
a
batch
of
hospital
bedding.
As
a
result,
several
patients
have
been
exposed
to
very
high
levels
of
detergents
still
present
in
the
"clean"
"clean"
bedding,
and
have
experienced
dermatological
reactions
to
this.
There
has
been
an
incident
with
multiple
exposures
to
several
patients.
Although
there
are
substance
administrations
involving
the
application
of
the
detergent
to
the
skin
of
the
patients,
it
is
expected
that
the
substance
administrations
would
not
be
directly
documented.
Seven
patients
who
are
residents
in
a
health
care
facility
for
the
elderly
mentally
ill
have
developed
respiratory
problems.
After
several
months
of
various
tests
having
been
performed
and
various
medications
prescribed
to
these
patients,
the
problem
is
traced
to
their
being
"sensitive"
"sensitive"
to
a
new
fungicide
used
in
the
wall
plaster
of
the
ward
where
these
patients
reside.
The
patients
have
been
continuously
exposed
to
the
fungicide.
Although
there
have
been
continuous
substance
administrations
(via
breathing)
this
would
not
normally
be
documented
as
a
substance
administration.
A
patient
with
osteoarthritis
of
the
knees
is
treated
symptomatically
using
analgesia,
paracetamol
(acetaminophen)
1g
up
to
four
times
a
day
for
pain
relief.
His
GP
does
not
realize
that
the
patient
has,
20
years
previously
(while
at
college)
had
severe
alcohol
addiction
problems,
and
now,
although
this
is
completely
under
control,
his
liver
has
suffered
significantly,
leaving
him
more
sensitive
to
hepatic
toxicity
from
paracetamol
use.
Later
that
year,
the
patient
returns
with
a
noticeable
level
of
jaundice.
Paracetamol
is
immediately
withdrawn
and
alternative
solutions
for
the
knee
pain
are
sought.
The
jaundice
gradually
subsides
with
conservative
management,
but
referral
to
the
gastroenterologist
is
required
for
advice
and
monitoring.
There
is
a
substance
administration
with
an
associated
exposure.
The
exposure
component
is
based
on
the
relative
toxic
level
of
the
substance
to
a
patient
with
a
compromised
liver
function.
A
patient
goes
to
their
GP
complaining
of
abdominal
pain,
having
been
discharged
from
the
local
hospital
ten
days'
previously
after
an
emergency
appendectomy.
The
GP
can
find
nothing
particularly
amiss,
and
presumes
it
is
post
operative
surgical
pain
that
will
resolve.
The
patient
returns
a
fortnight
later,
when
the
GP
prescribes
further
analgesia,
but
does
decide
to
request
an
outpatient
surgical
follow-up
appointment.
At
this
post-surgical
outpatient
review,
the
registrar
decides
to
order
an
ultrasound,
which,
when
performed
three
weeks
later,
shows
a
small
faint
inexplicable
mass.
A
laparoscopy
is
then
performed,
as
a
day
case
procedure,
and
a
piece
of
a
surgical
swab
is
removed
from
the
patient's
abdominal
cavity.
Thankfully,
a
full
recovery
then
takes
place.
This
is
a
procedural
sequelae.
There
may
be
an
Incident
recorded
for
this
also.
A
patient
is
slightly
late
for
a
regular
pacemaker
battery
check
in
the
Cardiology
department
of
the
local
hospital.
They
are
hurrying
down
the
second
floor
corridor.
A
sudden
summer
squall
has
recently
passed
over
the
area,
and
rain
has
come
in
through
an
open
corridor
window
leaving
a
small
puddle
on
the
corridor
floor.
In
their
haste,
the
patient
slips
in
the
puddle
and
falls
so
badly
that
they
have
to
be
taken
to
the
A&E
department,
where
it
is
discovered
on
investigation
they
have
slightly
torn
the
cruciate
ligament
in
their
left
knee.
This
is
not
an
exposure.
There
has
been
an
incident.
Usage
Notes:
This
class
deals
only
with
opportunity
and
not
the
outcome
of
the
exposure;
i.e.
not
all
exposed
parties
will
necessarily
experience
actual
harm
or
benefit.
Exposure
differs
from
Substance
Administration
by
the
absence
of
the
participation
of
a
performer
in
the
act.
The
following
participations
SHOULD
be
used
with
the
following
participations
to
distinguish
the
specific
entities:
The
exposed
entity
participates
via
the
"exposure
target"
"exposure
target"
(EXPTRGT)
participation.
An
entity
that
has
carried
the
agent
transmitted
in
the
exposure
participates
via
the
"exposure
source"
"exposure
source"
(EXSRC)
participation.
For
example:
a
person
or
animal
who
carried
an
infectious
disease
and
interacts
(EXSRC)
with
another
person
or
animal
(EXPTRGT)
transmitting
the
disease
agent;
a
place
or
other
environment
(EXSRC)
and
a
person
or
animal
(EXPTRGT)
who
is
exposed
in
the
presence
of
this
environment.
When
it
is
unknown
whether
a
participating
entity
is
the
source
of
the
agent
(EXSRC)
or
the
target
of
the
transmission
(EXPTRGT),
the
"exposure
participant"
"exposure
participant"
(EXPART)
is
used.
The
physical
(including
energy),
chemical
or
biological
substance
which
is
participating
in
the
exposure
uses
the
"exposure
agent"
"exposure
agent"
(EXPAGNT)
participation.
There
are
at
least
three
scenarios:
the
player
of
the
Role
that
participates
as
EXPAGNT
is
the
chemical
or
biological
substance
mixed
or
carried
by
the
scoper-entity
of
the
Role
(e.g.,
ingredient
role);
or
the
player
of
the
Role
that
participates
as
EXPAGNT
is
a
mixture
known
to
contain
the
chemical,
radiological
or
biological
substance
of
interest;
or
the
player
of
the
Role
that
participates
as
a
EXPAGNT
is
known
to
carry
the
agent
(i.e.,
the
player
is
a
fomite,
vector,
etc.).
The
Exposure.statusCode
attribute
should
be
interpreted
as
the
state
of
the
Exposure
business
object
(e.g.,
active,
aborted,
completed)
and
not
the
clinical
status
of
the
exposure
(e.g.,
probable,
confirmed).
The
clinical
status
of
the
exposure
should
be
associated
with
the
exposure
via
a
subject
observation.
Design
Comment:
The
usage
notes
require
a
clear
criterion
for
determining
whether
an
act
is
an
exposure
or
substance
administration-deleterious
potential,
uncertainty
of
actual
transmission,
or
otherwise.
SBADM
states
that
the
criterion
is
the
presence
of
a
performer-but
there
are
examples
above
that
call
this
criterion
into
question
(e.g.,
the
first
one,
concerning
a
dosing
error).
|
|
3
|
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.
|
|
3
|
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.
|
|
2
|
INC
|
incident
|
An
event
that
occurred
outside
of
the
control
of
one
or
more
of
the
parties
involved.
Includes
the
concept
of
an
accident.
|
|
2
|
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.
|
|
2
|
INVE
|
invoice
element
|
Represents
concepts
related
to
invoice
processing
in
health
care
|
|
2
|
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.
|
|
2
|
MPROT
|
monitoring
program
|
An
officially
or
unofficially
instituted
program
to
track
acts
of
a
particular
type
or
categorization.
|
|
2
|
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
|
|
3
|
(_ActClassROI)
Abstract
|
|
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
"subject"
"subject"
(SUBJ),
which
must
always
be
present.
|
|
4
|
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
"has
component"
"has
component"
(COMP).
In
each
boundary
criterion,
the
Act.code
names
the
dimension
and
the
Observation.value
specifies
the
range
of
values
inside
the
region.
Typically
the
bounded
dimension
is
continuous,
and
so
the
Observation.value
will
be
an
interval
(IVL)
data
type.
The
Observation.value
need
not
be
specified
if
the
respective
dimension
is
only
named
but
not
constrained.
For
example,
an
ROI
for
the
QT
interval
of
a
certain
beat
in
ECG
Lead
II
would
contain
2
boundary
criteria,
one
naming
the
interval
in
time
(constrained),
and
the
other
naming
the
interval
in
ECG
Lead
II
(only
named,
but
not
constrained).
|
|
4
|
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
"circling"
"circling"
a
region
in
a
schematic
picture
of
a
human
body.
The
units
of
the
coordinate
values
are
in
pixels.
The
origin
is
in
the
upper
left
hand
corner,
with
positive
X
values
going
to
the
right
and
positive
Y
values
going
down.
The
relationship
between
a
ROI
and
its
referenced
Act
is
specified
through
an
ActRelationship
of
type
"subject"
"subject"
(SUBJ),
which
must
always
be
present.
|
|
3
|
(_SubjectPhysicalPosition)
Abstract
|
|
The
spatial
relationship
of
a
subject
whether
human,
other
animal,
or
plant,
to
a
frame
of
reference
such
as
gravity
or
a
collection
device.
|
|
4
|
(_SubjectBodyPosition)
Abstract
Deprecated
|
|
Contains
codes
for
defining
the
observed,
physical
position
of
a
subject,
such
as
during
an
observation,
assessment,
collection
of
a
specimen,
etc.
ECG
waveforms
and
vital
signs,
such
as
blood
pressure,
are
two
examples
where
a
general,
observed
position
typically
needs
to
be
noted.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
5
|
LLD
Deprecated
|
left
lateral
decubitus
|
Lying
on
the
left
side.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
5
|
PRN
Deprecated
|
prone
|
Lying
with
the
front
or
ventral
surface
downward;
lying
face
down.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
5
|
RLD
Deprecated
|
right
lateral
decubitus
|
Lying
on
the
right
side.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
5
|
SFWL
Deprecated
|
Semi-Fowler's
|
A
semi-sitting
position
in
bed
with
the
head
of
the
bed
elevated
approximately
45
degrees.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
5
|
SIT
Deprecated
|
sitting
|
Resting
the
body
on
the
buttocks,
typically
with
upper
torso
erect
or
semi
erect.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
5
|
STN
Deprecated
|
standing
|
To
be
stationary,
upright,
vertical,
on
one's
legs.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
5
|
SUP
Deprecated
|
supine
|
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
6
|
RTRD
Deprecated
|
reverse
trendelenburg
|
Lying
on
the
back,
on
an
inclined
plane,
typically
about
30-45
degrees
with
head
raised
and
feet
lowered.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
6
|
TRD
Deprecated
|
trendelenburg
|
Lying
on
the
back,
on
an
inclined
plane,
typically
about
30-45
degrees,
with
head
lowered
and
feet
raised.
Deprecation
Comment:
This
concept
has
been
deprecated
because
it
does
not
describe
a
type
of
Act
(as
it
should
in
the
ActClass
code
system),
but
rather
encodes
the
result
or
value
of
an
observation.
The
same
code
has
been
added
to
the
ObservationValue
code
system.
|
|
3
|
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).
|
|
3
|
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.
|
|
3
|
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.
|
|
3
|
CNOD
Deprecated
|
Condition
Node
|
An
instance
of
Observation
of
a
Condition
at
a
point
in
time
that
includes
any
Observations
or
Procedures
associated
with
that
Condition
as
well
as
links
to
previous
instances
of
Condition
Node
for
the
same
Condition
Deprecation
Comment:
This
concept
has
been
deprecated
because
an
alternative
structure
for
tracking
the
evolution
of
a
problem
has
been
presented
and
adopted
by
the
Care
Provision
Work
Group.
|
|
3
|
COND
Deprecated
|
Condition
|
An
observable
finding
or
state
that
persists
over
time
and
tends
to
require
intervention
or
management,
and,
therefore,
distinguished
from
an
Observation
made
at
a
point
in
time;
may
exist
before
an
Observation
of
the
Condition
is
made
or
after
interventions
to
manage
the
Condition
are
undertaken.
Examples:
equipment
repair
status,
device
recall
status,
a
health
risk,
a
financial
risk,
public
health
risk,
pregnancy,
health
maintenance,
chronic
illness
|
|
4
|
CASE
Deprecated
|
public
health
case
|
A
public
health
case
is
an
Observation
representing
a
condition
or
event
that
has
a
specific
significance
for
public
health.
Typically
it
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.
An
outbreak
involving
multiple
individuals
may
be
considered
as
a
type
of
public
health
case.
A
public
health
case
definition
(Act.moodCode
=
"definition")
"definition")
includes
the
description
of
the
clinical,
laboratory,
and
epidemiologic
indicators
associated
with
a
disease
or
condition
of
interest
to
public
health.
There
are
case
definitions
for
conditions
that
are
reportable,
as
well
as
for
those
that
are
not.
There
are
also
case
definitions
for
outbreaks.
A
public
health
case
definition
is
a
construct
used
by
public
health
for
the
purpose
of
counting
cases,
and
should
not
be
used
as
clinical
indications
for
treatment.
Examples
include
AIDS,
toxic-shock
syndrome,
and
salmonellosis
and
their
associated
indicators
that
are
used
to
define
a
case.
|
|
5
|
OUTB
Deprecated
|
outbreak
|
An
outbreak
represents
a
series
of
public
health
cases.
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.
|
|
3
|
DGIMG
|
diagnostic
image
|
Class
for
holding
attributes
unique
to
diagnostic
images.
|
|
3
|
GEN
|
genomic
observation
|
Description:An
observation
of
genomic
phenomena.
|
|
4
|
DETPOL
|
determinant
peptide
|
Description:A
determinant
peptide
in
a
polypeptide
as
described
by
polypeptide.
|
|
4
|
EXP
|
expression
level
|
Description:An
expression
level
of
genes/proteins
or
other
expressed
genomic
entities.
|
|
4
|
LOC
|
locus
|
Description:The
position
of
a
gene
(or
other
significant
sequence)
on
the
genome.
|
|
4
|
PHN
|
phenotype
|
Description:A
genomic
phenomenon
that
is
expressed
externally
in
the
organism.
|
|
4
|
POL
|
polypeptide
|
Description:A
polypeptide
resulting
from
the
translation
of
a
gene.
|
|
4
|
SEQ
|
bio
sequence
|
Description:A
sequence
of
biomolecule
like
the
DNA,
RNA,
protein
and
the
like.
|
|
4
|
SEQVAR
|
bio
sequence
variation
|
Description:A
variation
in
a
sequence
as
described
by
BioSequence.
|
|
3
|
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.
|
|
3
|
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
"OBSCOR".
"OBSCOR".
And,
all
4
OBSCOR
would
be
contained
in
one
OBSSER
because
all
the
times
are
relative
to
the
same
origin
(beginning
of
the
recording)
and
all
the
ECG
signals
were
from
a
fixed
set
of
electrodes.
|
|
4
|
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.
|
|
3
|
POS
|
position
|
An
observation
denoting
the
physical
location
of
a
person
or
thing
based
on
a
reference
coordinate
system.
|
|
4
|
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.
|
|
4
|
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.
|
|
3
|
SPCOBS
|
specimen
observation
|
An
observation
on
a
specimen
in
a
laboratory
environment
that
may
affect
processing,
analysis
or
result
interpretation
|
|
3
|
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.
|
|
2
|
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.
|
|
3
|
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.
|
|
2
|
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
|
|
3
|
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.
|
|
3
|
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.
|
|
3
|
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.
|
|
3
|
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.
|
|
2
|
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.
|
|
3
|
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
|
|
3
|
SBEXT
|
Substance
Extraction
|
Description:
The
act
of
removing
a
substance
from
the
subject.
|
|
4
|
SPECCOLLECT
|
Specimen
Collection
|
A
procedure
for
obtaining
a
specimen
from
a
source
entity.
|
|
2
|
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.
|
|
2
|
REV
|
review
|
The
act
of
examining
and
evaluating
the
subject,
usually
another
act.
For
example,
"This
"This
prescription
needs
to
be
reviewed
in
2
months."
months."
|
|
2
|
SPCTRT
|
specimen
treatment
|
A
procedure
or
treatment
performed
on
a
specimen
to
prepare
it
for
analysis
|
|
2
|
SPLY
|
supply
|
Supply
orders
and
deliveries
are
simple
Acts
that
focus
on
the
delivered
product.
The
product
is
associated
with
the
Supply
Act
via
Participation.typeCode="product".
Participation.typeCode="product".
With
general
Supply
Acts,
the
precise
identification
of
the
Material
(manufacturer,
serial
numbers,
etc.)
is
important.
Most
of
the
detailed
information
about
the
Supply
should
be
represented
using
the
Material
class.
If
delivery
needs
to
be
scheduled,
tracked,
and
billed
separately,
one
can
associate
a
Transportation
Act
with
the
Supply
Act.
Pharmacy
dispense
services
are
represented
as
Supply
Acts,
associated
with
a
SubstanceAdministration
Act.
The
SubstanceAdministration
class
represents
the
administration
of
medication,
while
dispensing
is
supply.
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3
|
DIET
Deprecated
|
diet
|
Diet
services
are
supply
services,
with
some
aspects
resembling
Medication
services:
the
detail
of
the
diet
is
given
as
a
description
of
the
Material
associated
via
Participation.typeCode="product".
Participation.typeCode="product".
Medically
relevant
diet
types
may
be
communicated
in
the
Diet.code
attribute
using
domain
ActDietCode,
however,
the
detail
of
the
food
supplied
and
the
various
combinations
of
dishes
should
be
communicated
as
Material
instances.
Deprecation
Note
Class:
Use
either
the
Supply
class
(if
dealing
with
what
should
be
given
to
the
patient)
or
SubstanceAdministration
class
(if
dealing
with
what
the
patient
should
consume)
energyQuantity:
This
quantity
can
be
conveyed
by
using
a
Content
relationship
with
a
quantity
attribute
expressing
the
calories
carbohydrateQuantity:This
quantity
can
be
conveyed
using
a
Content
relationship
to
an
Entity
with
a
code
of
carbohydrate
and
a
quantity
attribute
on
the
content
relationship.
|
|
2
|
STORE
|
storage
|
The
act
of
putting
something
away
for
safe
keeping.
The
"something"
"something"
may
be
physical
object
such
as
a
specimen,
or
information,
such
as
observations
regarding
a
specimen.
|
|
2
|
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
"allowed"
"allowed"
substitution
when
creating
orders,
"actual"
"actual"
susbstitution
when
sending
events,
as
well
as
the
reason
for
the
substitution
and
who
was
responsible
for
it.
|
|
2
|
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.
|
|
2
|
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.)
|
|
2
|
XACT
|
financial
transaction
|
A
sub-class
of
Act
representing
any
transaction
between
two
accounts
whose
value
is
measured
in
monetary
terms.
In
the
"intent"
"intent"
mood,
communicates
a
request
for
a
transaction
to
be
initiated,
or
communicates
a
transfer
of
value
between
two
accounts.
In
the
"event"
"event"
mood,
communicates
the
posting
of
a
transaction
to
an
account.
|
|
2
|
(_ActClassContainer)
Abstract
|
|
|
|
3
|
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.
|
|
3
|
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
"organizer
tree".
"organizer
tree".
The
record
entries
relating
to
a
single
clinical
session
are
usually
grouped
under
headings
that
represent
phases
of
the
encounter,
or
assist
with
layout
and
navigation.
Clinical
headings
usually
reflect
the
clinical
workflow
during
a
care
session,
and
might
also
reflect
the
main
author's
reasoning
processes.
Much
research
has
demonstrated
that
headings
are
used
differently
by
different
professional
groups
and
specialties,
and
that
headings
are
not
used
consistently
enough
to
support
safe
automatic
processing
of
the
E
H
R.
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versions:
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|
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Terminology