This
page
is
part
of
the
FHIR
Specification
(v0.0.82:
DSTU
(v5.0.0-draft-final:
Final
QA
Preview
for
R5
-
see
ballot
notes
1).
).
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:
R5
R4B
R4
R3
R2
Patient
Care
Work
Group
| Maturity Level : 0 | Trial Use | Security Category : Patient | Compartments : Patient , Practitioner , RelatedPerson |
Detailed Descriptions for the elements in the AdverseEvent resource.
| AdverseEvent | |
| Element Id | AdverseEvent |
| Definition |
|
| Short Display | An event that may be related to unintended effects on a patient or research participant |
| Cardinality | 0..* |
| Type | DomainResource |
| Alternate Names | AE |
| Summary | false |
| AdverseEvent.identifier | |
| Element Id | AdverseEvent.identifier |
| Definition | Business identifiers assigned to this adverse event by the performer or other systems which remain constant as the resource is updated and propagates from server to server. |
| Short Display | Business identifier for the event |
| Note | This is a business identifier, not a resource identifier (see discussion ) |
| Cardinality | 0..* |
| Type | Identifier |
| Requirements | Allows identification of the adverse event as it is known by various participating systems and in a way that remains consistent across servers. |
| Summary | true |
| Comments | This is a business identifier, not a resource identifier (see discussion ). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. |
| AdverseEvent.status | |
| Element Id | AdverseEvent.status |
| Definition | The current state of the adverse event or potential adverse event. |
| Short Display | in-progress | completed | entered-in-error | unknown |
| Cardinality | 1..1 |
| Terminology Binding |
Adverse
Event
Status
(
|
| Type | code |
| Is Modifier | true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid) |
| Summary | true |
| Comments | This is not the reporting of the event to any regulatory or quality organization. This is not the outcome of the patient's condition. |
| AdverseEvent.actuality | |
| Element Id | AdverseEvent.actuality |
| Definition |
Whether the event actually happened or was a near miss. Note that this is independent of whether anyone was affected or harmed or how severely. |
| Short Display | actual | potential |
| Cardinality | 1..1 |
| Terminology Binding | Adverse Event Actuality ( Required ) |
| Type | code |
| Is Modifier | true (Reason: This element is labeled as a modifier because it has a potential code that indicates the adverse event did not actually happen.) |
| Summary | true |
| Comments | AllergyIntolerance should be used for the initial capture or recording of the individual's propensity to an adverse reaction to a substance. If an AllergyIntolerance does not exist, then an adverse reaction should be recorded as an AllergyIntolerance. If an AllergyIntolerance does exist and the substance was given, then an adverse reaction should be recorded as an AdverseEvent due to the aberrant workflow. |
| AdverseEvent.category | |
| Element Id | AdverseEvent.category |
| Definition |
The
overall
type
of
event,
intended
for
|
| Short Display | wrong-patient | procedure-mishap | medication-mishap | device | unsafe-physical-environment | hospital-aquired-infection | wrong-body-site |
| Cardinality | 0..* |
| Terminology Binding | Adverse Event Category ( Example ) |
| Type | CodeableConcept |
| Summary | true |
| AdverseEvent.code | |
| Element Id | AdverseEvent.code |
| Definition | Specific event that occurred or that was averted, such as patient fall, wrong organ removed, or wrong blood transfused. |
| Short Display | Event or incident that occurred or was averted |
| Cardinality | 0..1 |
| Terminology Binding | AdverseEvent Type ( Example ) |
| Type | CodeableConcept |
| Summary | true |
| AdverseEvent.subject | |
| Element Id | AdverseEvent.subject |
| Definition |
This subject or group impacted by the event. |
| Short Display | Subject impacted by event |
| Cardinality | 1..1 |
| Type | Reference ( Patient | Group | Practitioner | RelatedPerson | ResearchSubject ) |
| Requirements | Allows for exposure of biohazard (such as legionella) to a group of individuals in a hospital. |
| Alternate Names | patient |
| Summary | true |
| Comments | If AdverseEvent.resultingEffect differs among members of the group, then use Patient as the subject. |
|
AdverseEvent.encounter
|
|
| Element Id | AdverseEvent.encounter |
| Definition |
|
| Short Display | The Encounter associated with the start of the AdverseEvent |
| Cardinality | 0..1 |
| Type | Reference ( Encounter ) |
| Summary | true |
| Comments |
This
will
typically
be
the
encounter
the
event
occurred
within,
but
some
activities
may
be
initiated
prior
to
|
| AdverseEvent.occurrence[x] | |
| Element Id | AdverseEvent.occurrence[x] |
| Definition | The date (and perhaps time) when the adverse event occurred. |
| Short Display | When the event occurred |
| Cardinality | 0..1 |
| Type | dateTime | Period | Timing |
| [x] Note | See Choice of Datatypes for further information about how to use [x] |
| Alternate Names | timing |
| Summary | true |
| AdverseEvent.detected | |
| Element Id | AdverseEvent.detected |
| Definition | Estimated or actual date the AdverseEvent began, in the opinion of the reporter. |
| Short Display | When the event was detected |
| Cardinality | 0..1 |
| Type | dateTime |
| Summary | true |
| AdverseEvent.recordedDate | |
| Element Id | AdverseEvent.recordedDate |
| Definition | The date on which the existence of the AdverseEvent was first recorded. |
| Short Display | When the event was recorded |
| Cardinality | 0..1 |
| Type | dateTime |
| Summary | true |
| Comments | The recordedDate represents the date when this particular AdverseEvent record was created in the system, not the date of the most recent update. The date of the last record modification can be retrieved from the resource metadata. |
| AdverseEvent.resultingEffect | |
| Element Id | AdverseEvent.resultingEffect |
| Definition | Information about the condition that occurred as a result of the adverse event, such as hives due to the exposure to a substance (for example, a drug or a chemical) or a broken leg as a result of the fall. |
| Short Display | Effect on the subject due to this event |
| Cardinality | 0..* |
| Type | Reference ( Condition | Observation ) |
| Summary | true |
| AdverseEvent.location | |
| Element Id | AdverseEvent.location |
| Definition | The information about where the adverse event occurred. |
| Short Display | Location where adverse event occurred |
| Cardinality | 0..1 |
| Type | Reference ( Location ) |
| Summary | true |
| AdverseEvent.seriousness | |
| Element Id | AdverseEvent.seriousness |
| Definition | Assessment whether this event, or averted event, was of clinical importance. |
| Short Display | Seriousness or gravity of the event |
| Cardinality | 0..1 |
| Terminology Binding | Adverse Event Seriousness ( Example ) |
| Type | CodeableConcept |
| Summary | true |
| Comments |
Using
an
example,
a
rash
can
have
an
AdverseEvent.resultingEffect.severity
=
severe,
yet
an
AdverseEvent.seriousness
=
non-serious.
Alternatively,
a
medication
given
with
the
wrong
dose
(chemotherapy
given
with
too
low
of
a
dose)
can
have
an
AdverseEvent.resultingEffect.severity
=
mild,
yet
an
adverseEvent.seriousness
=
serious.
Another
example
would
be
a
beta
blocker
clinical
trial
where
patients
with
asthma
should
be
excluded,
yet
a
patient
with
asthma
was
included
and
|
| AdverseEvent.outcome | |
| Element Id | AdverseEvent.outcome |
| Definition | Describes the type of outcome from the adverse event, such as resolved, recovering, ongoing, resolved-with-sequelae, or fatal. |
| Short Display | Type of outcome from the adverse event |
| Cardinality | 0..* |
| Terminology Binding | AdverseEvent Outcome ( Example ) |
| Type | CodeableConcept |
| Summary | true |
| AdverseEvent.recorder | |
| Element Id | AdverseEvent.recorder |
| Definition | Information on who recorded the adverse event. May be the patient or a practitioner. |
| Short Display | Who recorded the adverse event |
| Cardinality | 0..1 |
| Type | Reference ( Patient | Practitioner | PractitionerRole | RelatedPerson | ResearchSubject ) |
| Summary | true |
| AdverseEvent.participant | |
| Element Id | AdverseEvent.participant |
| Definition | Indicates who or what participated in the adverse event and how they were involved. |
| Short Display | Who was involved in the adverse event or the potential adverse event and what they did |
| Cardinality | 0..* |
| Summary | true |
| AdverseEvent.participant.function | |
| Element Id | AdverseEvent.participant.function |
| Definition | Distinguishes the type of involvement of the actor in the adverse event, such as contributor or informant. |
| Short Display | Type of involvement |
| Cardinality | 0..1 |
| Terminology Binding | AdverseEvent Participant Function ( Example ) |
| Type | CodeableConcept |
| Summary | true |
| AdverseEvent.participant.actor | |
| Element Id | AdverseEvent.participant.actor |
| Definition | Indicates who or what participated in the event. |
| Short Display | Who was involved in the adverse event or the potential adverse event |
| Cardinality | 1..1 |
| Type | Reference ( Practitioner | PractitionerRole | Organization | CareTeam | Patient | Device | RelatedPerson | ResearchSubject ) |
| Summary | true |
| Comments | For example, the physician prescribing a drug, a nurse administering the drug, a device that administered the drug, a witness to the event, or an informant of clinical history. |
| AdverseEvent.study | |
| Element Id | AdverseEvent.study |
| Definition | The research study that the subject is enrolled in. |
| Short Display | Research study that the subject is enrolled in |
| Cardinality | 0..* |
| Type | Reference ( ResearchStudy ) |
| Summary | true |
| AdverseEvent.expectedInResearchStudy | |
| Element Id | AdverseEvent.expectedInResearchStudy |
| Definition |
Considered
likely
or
probable
or
anticipated
in
the
research
study.
Whether
the
reported
event
matches
any
of
the
outcomes
for
the
patient
that
are
|
| Short Display | Considered likely or probable or anticipated in the research study |
| Cardinality | 0..1 |
| Type | boolean |
| Summary | false |
| AdverseEvent.suspectEntity | |
| Element Id | AdverseEvent.suspectEntity |
| Definition | Describes the entity that is suspected to have caused the adverse event. |
| Short Display | The suspected agent causing the adverse event |
| Cardinality | 0..* |
| Summary | true |
| AdverseEvent.suspectEntity.instance[x] | |
| Element Id | AdverseEvent.suspectEntity.instance[x] |
| Definition |
Identifies
the
actual
instance
of
what
caused
the
adverse
event.
May
be
a
|
| Short Display | Refers to the specific entity that caused the adverse event |
| Cardinality | 1..1 |
| Type | CodeableConcept | Reference ( Immunization | Procedure | Substance | Medication | MedicationAdministration | MedicationStatement | Device | BiologicallyDerivedProduct | ResearchStudy ) |
| [x] Note | See Choice of Datatypes for further information about how to use [x] |
| Alternate Names | Substance or Medication or Device |
| Summary | true |
| AdverseEvent.suspectEntity.causality | |
| Element Id | AdverseEvent.suspectEntity.causality |
| Definition | Information on the possible cause of the event. |
| Short Display | Information on the possible cause of the event |
| Cardinality | 0..1 |
| Summary | true |
| AdverseEvent.suspectEntity.causality.assessmentMethod | |
| Element Id | AdverseEvent.suspectEntity.causality.assessmentMethod |
| Definition | The method of evaluating the relatedness of the suspected entity to the event. |
| Short Display | Method of evaluating the relatedness of the suspected entity to the event |
| Cardinality | 0..1 |
| Terminology Binding | Adverse Event Causality Method ( Example ) |
| Type | CodeableConcept |
| Summary | true |
| AdverseEvent.suspectEntity.causality.entityRelatedness | |
| Element Id | AdverseEvent.suspectEntity.causality.entityRelatedness |
| Definition | The result of the assessment regarding the relatedness of the suspected entity to the event. |
| Short Display | Result of the assessment regarding the relatedness of the suspected entity to the event |
| Cardinality | 0..1 |
| Terminology Binding | Adverse Event Causality Assessment ( Example ) |
| Type | CodeableConcept |
| Summary | true |
| AdverseEvent.suspectEntity.causality.author | |
| Element Id | AdverseEvent.suspectEntity.causality.author |
| Definition | The author of the information on the possible cause of the event. |
| Short Display | Author of the information on the possible cause of the event |
| Cardinality | 0..1 |
| Type | Reference ( Practitioner | PractitionerRole | Patient | RelatedPerson | ResearchSubject ) |
| Summary | true |
| AdverseEvent.contributingFactor | |
| Element Id | AdverseEvent.contributingFactor |
| Definition | The contributing factors suspected to have increased the probability or severity of the adverse event. |
| Short Display | Contributing factors suspected to have increased the probability or severity of the adverse event |
| Cardinality | 0..* |
| Summary | true |
| AdverseEvent.contributingFactor.item[x] | |
| Element Id | AdverseEvent.contributingFactor.item[x] |
| Definition | The item that is suspected to have increased the probability or severity of the adverse event. |
| Short Display | Item suspected to have increased the probability or severity of the adverse event |
| Cardinality | 1..1 |
| Terminology Binding | AdverseEvent Contributing Factor ( Example ) |
| Type | Reference ( Condition | Observation | AllergyIntolerance | FamilyMemberHistory | Immunization | Procedure | Device | DeviceUsage | DocumentReference | MedicationAdministration | MedicationStatement )| CodeableConcept |
| [x] Note | See Choice of Datatypes for further information about how to use [x] |
| Summary | true |
| AdverseEvent.preventiveAction | |
| Element Id | AdverseEvent.preventiveAction |
| Definition | Preventive actions that contributed to avoiding the adverse event. |
| Short Display | Preventive actions that contributed to avoiding the adverse event |
| Cardinality | 0..* |
| Summary | true |
| AdverseEvent.preventiveAction.item[x] | |
| Element Id | AdverseEvent.preventiveAction.item[x] |
| Definition | The action that contributed to avoiding the adverse event. |
| Short Display | Action that contributed to avoiding the adverse event |
| Cardinality | 1..1 |
| Terminology Binding | AdverseEvent Preventive Action ( Example ) |
| Type | Reference ( Immunization | Procedure | DocumentReference | MedicationAdministration | MedicationRequest )| CodeableConcept |
| [x] Note | See Choice of Datatypes for further information about how to use [x] |
| Summary | true |
| AdverseEvent.mitigatingAction | |
| Element Id | AdverseEvent.mitigatingAction |
| Definition | The ameliorating action taken after the adverse event occured in order to reduce the extent of harm. |
| Short Display | Ameliorating actions taken after the adverse event occured in order to reduce the extent of harm |
| Cardinality | 0..* |
| Summary | true |
| AdverseEvent.mitigatingAction.item[x] | |
| Element Id | AdverseEvent.mitigatingAction.item[x] |
| Definition | The ameliorating action taken after the adverse event occured in order to reduce the extent of harm. |
| Short Display | Ameliorating action taken after the adverse event occured in order to reduce the extent of harm |
| Cardinality | 1..1 |
| Terminology Binding | AdverseEvent Mitigating Action ( Example ) |
| Type | Reference ( Procedure | DocumentReference | MedicationAdministration | MedicationRequest )| CodeableConcept |
| [x] Note | See Choice of Datatypes for further information about how to use [x] |
| Summary | true |
| AdverseEvent.supportingInfo | |
| Element Id | AdverseEvent.supportingInfo |
| Definition | Supporting information relevant to the event. |
| Short Display | Supporting information relevant to the event |
| Cardinality | 0..* |
| Summary | true |
| AdverseEvent.supportingInfo.item[x] | |
| Element Id | AdverseEvent.supportingInfo.item[x] |
| Definition |
Relevant
past
history
for
the
subject.
In
a
clinical
care
context,
an
example
being
a
patient
had
an
adverse
event
following
a
pencillin
administration
and
the
patient
had
a
previously
documented
penicillin
allergy.
In
a
clinical
trials
context,
an
example
is
a
bunion
or
rash
that
was
present
prior
to
the
study.
Additionally,
the
supporting
item
can
be
a
document
that
is
relevant
to
this
instance
of
the
adverse
event
that
is
not
part
of
the
|
| Short Display | Subject medical history or document relevant to this adverse event |
| Cardinality | 1..1 |
| Terminology Binding | AdverseEvent Supporting Information ( Example ) |
| Type | Reference ( Condition | Observation | AllergyIntolerance | FamilyMemberHistory | Immunization | Procedure | DocumentReference | MedicationAdministration | MedicationStatement | QuestionnaireResponse )| CodeableConcept |
| [x] Note | See Choice of Datatypes for further information about how to use [x] |
| Summary | true |
| AdverseEvent.note | |
| Element Id | AdverseEvent.note |
| Definition | Comments made about the adverse event by the performer, subject or other participants. |
| Short Display | Comment on adverse event |
| Cardinality | 0..* |
| Type | Annotation |
| Summary | true |