|
|
General
|
|
Resources
that
provide
core
clinical
record
keeping
-
focused
on
the
content
of
the
provider/patient
encounter
|
|
Name
|
Aliases
|
Description
|
AdverseReaction
AllergyIntolerance
|
Allergy,
Intolerance
|
Records
Risk
of
harmful
or
undesirable,
physiological
response
which
is
unique
to
an
unexpected
reaction
suspected
individual
and
associated
with
exposure
to
be
related
a
substance.
|
|
ClinicalImpression
| |
A
record
of
a
clinical
assessment
performed
to
determine
what
problem(s)
may
affect
the
exposure
of
patient
and
before
planning
the
reaction
subject
treatments
or
management
strategies
that
are
best
to
manage
a
substance.
patient's
condition.
Assessments
are
often
1:1
with
a
clinical
consultation
/
encounter,
but
this
varies
greatly
depending
on
the
clinical
workflow.
This
resource
is
called
"ClinicalImpression"
rather
than
"ClinicalAssessment"
to
avoid
confusion
with
the
recording
of
assessment
tools
such
as
Apgar
score.
|
AllergyIntolerance
Condition
|
|
Adverse
Sensitivity
Use
to
record
detailed
information
about
conditions,
problems
or
diagnoses
recognized
by
a
clinician.
There
are
many
uses
including:
recording
a
diagnosis
during
an
encounter;
populating
a
problem
list
or
a
summary
statement,
such
as
a
discharge
summary.
|
Indicates
the
patient
has
ProcedureRequest
| |
A
request
for
a
susceptibility
procedure
to
be
performed.
May
be
a
proposal
or
an
adverse
reaction
upon
exposure
order.
|
|
Procedure
| |
An
action
that
is
or
was
performed
on
a
patient.
This
can
be
a
physical
intervention
like
an
operation,
or
less
invasive
like
counseling
or
hypnotherapy.
|
|
ReferralRequest
|
ReferralRequest
TransferOfCare
Request
|
Used
to
record
and
send
details
about
a
specified
substance.
request
for
referral
service
or
transfer
of
a
patient
to
the
care
of
another
provider
or
provider
organization.
|
|
RiskAssessment
|
Prognosis
|
An
assessment
of
the
likely
outcome(s)
for
a
patient
or
other
subject
as
well
as
the
likelihood
of
each
outcome.
|
|
|
Care
Provision
|
|---|
|
Care
planning,
tracking
care
provided
|
|
Name
|
Aliases
|
Description
|
|
CarePlan
|
Care
Team
|
Describes
the
intention
of
how
one
or
more
practitioners
intend
to
deliver
care
for
a
particular
patient
patient,
group
or
community
for
a
period
of
time,
possibly
limited
to
care
for
a
specific
condition
or
set
of
conditions.
|
Condition
Goal
|
|
Use
to
record
detailed
information
about
conditions,
problems
or
diagnoses
recognized
by
a
clinician.
There
are
many
uses
including:
recording
Describes
the
intended
objective(s)
for
a
Diagnosis
during
patient,
group
or
organization
care,
for
example,
weight
loss,
restoring
an
Encounter;
populating
activity
of
daily
living,
obtaining
herd
immunity
via
immunization,
meeting
a
problem
List
process
improvement
objective,
etc.
|
|
DetectedIssue
|
DDI,
drug-drug
interaction,
Contraindication
|
Indicates
an
actual
or
potential
clinical
issue
with
or
between
one
or
more
active
or
proposed
clinical
actions
for
a
Summary
Statement,
such
as
a
Discharge
Summary.
patient;
e.g.
Drug-drug
interaction,
Ineffective
treatment
frequency,
Procedure-condition
conflict,
etc.
|
FamilyHistory
FamilyMemberHistory
|
|
Significant
health
events
and
conditions
for
people
a
person
related
to
the
subject
patient
relevant
in
the
context
of
care
for
the
subject.
patient.
|
Procedure
NutritionOrder
|
Diet
Order,
Diet,
Nutritional
Supplement
|
An
action
that
is
performed
on
a
patient.
This
can
be
A
request
to
supply
a
physical
'thing'
like
an
operation,
or
less
invasive
like
counseling
diet,
formula
feeding
(enteral)
or
hypnotherapy.
oral
nutritional
supplement
to
a
patient/resident.
|
Questionnaire
VisionPrescription
|
Form
|
A
structured
set
of
questions
and
their
answers.
The
Questionnaire
may
contain
questions,
answers
or
both.
The
questions
are
ordered
and
grouped
into
coherent
subsets,
corresponding
to
the
structure
of
An
authorization
for
the
grouping
supply
of
the
underlying
questions.
glasses
and/or
contact
lenses
to
a
patient.
|
|
Medications
&
Immunizations
Medication,
Immunization
|
Support
the
medication
&
Immunization
process
&
immunization
processes
|
|
Name
|
Aliases
|
Description
|
|
Medication
|
|
Primarily
This
resource
is
primarily
used
for
the
identification
and
definition
of
Medication,
but
also
a
medication.
It
covers
the
ingredients
and
packaging.
the
packaging
for
a
medication.
|
MedicationPrescription
MedicationOrder
|
Prescription
|
An
order
for
both
supply
of
the
medication
and
the
instructions
for
administration
of
the
medicine
medication
to
a
patient.
The
resource
is
called
"MedicationOrder"
rather
than
"MedicationPrescription"
to
generalize
the
use
across
inpatient
and
outpatient
settings
as
well
as
for
care
plans,
etc.
|
|
MedicationAdministration
|
|
Describes
the
event
of
a
patient
consuming
or
otherwise
being
given
a
dose
of
administered
a
medication.
This
may
be
as
simple
as
swallowing
a
tablet
or
it
may
be
a
long
running
infusion.
Related
resources
tie
this
event
to
the
authorizing
prescription,
and
the
specific
encounter
between
patient
and
health
care
practitioner.
|
|
MedicationDispense
|
|
Dispensing
Indicates
that
a
medication
product
is
to
be
or
has
been
dispensed
for
a
named
patient.
person/patient.
This
includes
a
description
of
the
supply
medication
product
(supply)
provided
and
the
instructions
for
administering
the
medication.
The
medication
dispense
is
the
result
of
a
pharmacy
system
responding
to
a
medication
order.
|
|
MedicationStatement
|
|
A
record
of
a
medication
that
is
being
taken
consumed
by
a
patient.
A
MedicationStatement
may
indicate
that
the
patient
may
be
taking
the
medication
now,
or
has
taken
the
medication
in
the
past
or
will
be
taking
the
medication
in
the
future.
The
source
of
this
information
can
be
the
patient,
significant
other
(such
as
a
family
member
or
spouse),
or
a
clinician.
A
common
scenario
where
this
information
is
captured
is
during
the
history
taking
process
during
a
patient
visit
or
stay.
The
medication
information
may
come
from
e.g.
the
patient's
memory,
from
a
prescription
bottle,
or
from
a
list
of
medications
the
patient,
clinician
or
other
party
maintains
The
primary
difference
between
a
medication
statement
and
a
medication
administration
is
that
the
medication
administration
has
been
given
to
complete
administration
information
and
is
based
on
actual
administration
information
from
the
person
who
administered
the
medication.
A
medication
statement
is
often,
if
not
always,
less
specific.
There
is
no
required
date/time
when
the
medication
was
administered,
in
fact
we
only
know
that
a
source
has
reported
the
patient
is
taking
this
medication,
where
details
such
as
time,
quantity,
or
rate
or
even
medication
product
may
be
incomplete
or
missing
or
less
precise.
As
stated
earlier,
the
record
is
medication
statement
information
may
come
from
the
result
of
patient's
memory,
from
a
report
prescription
bottle
or
from
a
list
of
medications
the
patient
patient,
clinician
or
another
clinician.
other
party
maintains.
Medication
administration
is
more
formal
and
is
not
missing
detailed
information.
|
|
Immunization
|
|
Immunization
Describes
the
event
information.
of
a
patient
being
administered
a
vaccination
or
a
record
of
a
vaccination
as
reported
by
a
patient,
a
clinician
or
another
party
and
may
include
vaccine
reaction
information
and
what
vaccination
protocol
was
followed.
|
|
ImmunizationRecommendation
|
|
A
patient's
point-of-time
point-in-time
immunization
status
and
recommendation
(i.e.
forecasting
a
patient's
immunization
eligibility
according
to
a
published
schedule)
with
optional
supporting
justification.
|
|
|
Diagnostics
|
|
Provider
support
for
diagnostic
services
-
lab,
pathology,
imaging,
etc
|
|
Name
|
Aliases
|
Description
|
|
Observation
|
Vital
Signs,
Measurement,
Results
|
Measurements
and
simple
assertions
made
about
a
patient,
device
or
other
subject.
|
|
DiagnosticReport
|
Report,
Test,
Result,
Results,
Labs
|
The
findings
and
interpretation
of
diagnostic
tests
performed
on
patients,
groups
of
patients,
devices,
and
locations,
and/or
specimens
derived
from
these.
The
report
includes
clinical
context
such
as
requesting
and
provider
information,
and
some
mix
of
atomic
results,
images,
textual
and
coded
interpretation,
interpretations,
and
formatted
representation
of
diagnostic
reports.
|
|
DiagnosticOrder
|
Report,
Test,
Result,
Results,
Labs
|
A
record
of
a
request
for
a
diagnostic
investigation
service
to
be
performed.
|
|
ImagingStudy
|
Manifest,
XDS-I
summary
|
Manifest
of
a
set
Representation
of
images
the
content
produced
in
a
DICOM
imaging
study.
The
A
study
comprises
a
set
of
series,
each
of
which
includes
a
set
of
Service-Object
Pair
Instances
(SOP
Instances
-
images
may
include
every
image
in
the
study,
or
it
may
be
an
incomplete
sample,
such
as
other
data)
acquired
or
produced
in
a
list
common
context.
A
series
is
of
key
images.
only
one
modality
(e.g.
X-ray,
CT,
MR,
ultrasound),
but
a
study
may
have
multiple
series
of
different
modalities.
|
Specimen
ImagingObjectSelection
|
Manifest,
XDS-I
summary,
Key
Images
|
Sample
A
manifest
of
a
set
of
DICOM
Service-Object
Pair
Instances
(SOP
Instances).
The
referenced
SOP
Instances
(images
or
other
content)
are
for
analysis.
a
single
patient,
and
may
be
from
one
or
more
studies.
The
referenced
SOP
Instances
have
been
selected
for
a
purpose,
such
as
quality
assurance,
conference,
or
consult.
Reflecting
that
range
of
purposes,
typical
ImagingObjectSelection
resources
may
include
all
SOP
Instances
in
a
study
(perhaps
for
sharing
through
a
Health
Information
Exchange);
key
images
from
multiple
studies
(for
reference
by
a
referring
or
treating
physician);
a
multi-frame
ultrasound
instance
("cine"
video
clip)
and
a
set
of
measurements
taken
from
that
instance
(for
inclusion
in
a
teaching
file);
and
so
on.
|
Device
Interactions
Specimen
|
|
Support
A
sample
to
be
used
for
reading
measurements
made
by
devices
analysis.
|
DeviceObservationReport
BodySite
|
anatomical
location
|
Describes
Record
details
about
the
data
produced
by
anatomical
location
of
a
device
at
specimen
or
body
part.
This
resource
may
be
used
when
a
point
in
time.
coded
concept
does
not
provide
the
necessary
detail
needed
for
the
use
case.
|
Additional
Resources
will
be
added
in
the
future.
A
list
of
hypothesized
resources
can
be
found
on
the
HL7
wiki
.
Feel
free
to
add
any
you
think
are
missing
or
engage
with
one
of
the
HL7
Work
Groups
to
submit
a
proposal
to
define
a
resource
of
particular
interest.
|
Propose
a
change