Link to Subjects
Link to Stewardship and Class interests and DIMs
This data model was HTML encoded by software prepared for the JWG-CDM. Comments on presentation links or any bugs encountered may be addressed to:
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Organization: Health Level Seven
Version: V 0-82 19970812
Developed by: Modeling and Methodology
A collection of master tables related to clinical pathways.
This subject area is a collection of datatypes that have components. The datatypes are modeled as abstract classes with their components modeled as attributes.
This subject area is a collection of classes representing datatypes used in this model.
Attribute names follow the format:
[ClassName-][{QualifierName-}]DatatypeName.
ClassName is the name of the Class the attribute is a property of. In most cases the ClassName is omitted. If ClassName is omitted it is still assumed to be part of the attribute name for the purpose of determining attribute name uniqueness within the model. One or more QualifierNames may be used in an attribute name to constrain the scope of the DatatypeName. The final word in an attribute name is the DatatypeName. It must correspond to a datatype specified in this subject area.
RIM Datatypes
The datatypes are categories of the types of data values allowed for the attributes they are assigned to. There are sixteen datatype names used in this draft HL7 RIM. They are:
Address, Amount, Code, Date, DateTime, Description, Identifier, Indicator, Name, Number, Percentage, PersonName, Phone, Quantity, Text
A collection of classes related to a guarantor contract.
A collection of classes related to healthcare benefit plans.
A collection of subject areas related to the financial aspects of Healthcare.
A collection of classes related to Healthcare service providers.
A collection of subject areas related to healthcare stakeholders.
A collection of classes designated used as reference classes to master tables.
A collection of classes describing observation service types.
A collection of classes related to organizational stakeholders.
A collection of subject areas related to patients.
A collection of classes related to the patient billing account.
A collection of classes related to patient specific clinical pathways or treatment plans.
A collection of classes related to patient encounters.
A collection of subject areas related to patient encounters and patient services
A collection of classes related to the patient service events.
A collection of classes related to location of patient services.
A collection of classes related to patient service orders.
A collection of classes related to person stakeholder.
A collection of services related to pharmacy treatment service events.
A collection of classes related to service catalog items.
A collection of classes depicting datatypes which have a simple structure, are not comprised of components, are not compound.
A collection of classes in related to stakeholders.
This draft HL7 Reference Information Model (RIM) is the result of the first HL7 RIM harmonization cycle. RIM change proposals from several HL7 Technical Committees were reviewed and acted upon during a RIM Harmonization Meeting held July 8 & 9, 1997 in Indianapolis, Indiana.
The updated version of the HL7 RIM will be provided to the Technical Committees and Special Interest Groups of HL7 for their use during the August 1997 Working Group meeting.
Comments on this model should be addressed to the co-chairs of the Methodology and Modeling Committee and/or sent to the M&M e-mail list at hl7-mnm@mayo.edu
Class steward is Information Management (Medical Records)
An authoritative instruction or direction of a patient regarding their healthcare or the disposition of their remains.
An indication as to whether the patient was mentally competent when completing the advance directive.
A code depicting the nature of the advance directive.
The level of disclosure allowed for this advance directive.
A free for text describing quality of life preference of the patient to be used in making intervention decisions.
The name of the patient's preferred mortuary.
The date the advance directive was notarized.
Class steward is Information Management (Medical Records)
A person that is witness to a patient's advance directive.
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
A planned patient encounter set for a specific time and place.
A code depicting the disposition of the appointment (e.g., pending, canceled, rescheduled, . . .).
A code depicting the reason the appointment is being requested.
The date and time the appointment was canceled.
A code depicting why the appointment was canceled.
The amount of time the scheduled encounter is expected to last.
The expected end date and time of the patient encounter
Text providing the service(s) expected to be provided in the scheduled encounter.
The expected date and time for the start of a patient encounter.
A unique identifier assigned to an appointment.
An indication as to whether the appointment is an overbook.
The data and time the scheduling of the appointment began.
The date and time the scheduling of the appointment was completed.
A code depicting the status of scheduling the appointment.
A code depicting the urgency to be seen by a healthcare provider.
A code used to classify a visit.
The priority assigned to an appointment request placed on a wait list.
Class steward is Information Management (Medical Records)
All instances that record information related to the relationship between a Health Chart Document Header and the Authenticator of the document.
Rationale:
OpenIssue:
This records the date that the contents of the healthcare document were verified by the authenticator.
Rationale:
OpenIssue:
Code indicating the type of authentication that was carried out for the document
Rationale:
OpenIssue:
Class steward is Patient Administration
A billing account that has been turned over for bad debt collection.
The amount recovered on a bad debt patient account.
|PV1^33^00163^Bad Debt Recovery Amount|
The amount of the patient billing account that was turned over to bad debt for collection.
|PV1^32^00162^Bad Debt Transfer Amount|
The date the patient billing account was transferred to bad debt status.
|PV1^30^00160^Transfer to Bad Debt Date|
A code depicting the reason the patient billing account was transferred to bad debts.
|PV1^29^00159^Transfer to Bad Debt Code|
Class steward is Patient Administration
A role assumed by an organization stakeholder. This role is assigned one or more bad debt billing account.
Class steward is Patient Administration
Billing account information particular to the national uniform billing form.
A code depicting a condition.
|UB1^7^00536^Condition Code (35-39)| |UB1^12^00541^Spec Program Indicator (44) | |UB2^3^00555^Condition Code (24-30)|
A code depicting a event.
|UB1^16^00545^Occurrence (28 32) | |UB2^7^00559^Occurrence Code & Date (32-35)|
The date of the event depicted in occurrence code.
|UB2^7^00559^Occurrence Code & Date (32-35)|
A code depicting an event which occurs over a span of time.
|UB1^13^00542^PSRO/UR Approval Indicator (87) | |UB1^17^00546^Occurrence Span (33) | |UB2^8^00560^Occurrence Span Code/Dates (36)|
The from date of the event depicted in occurrence span code.
|UB1^14^00543^PSRO/UR Approved Stay Fm (88) | |UB1^18^00547^Occur Span Start Date(33) | |UB2^8^00560^Occurrence Span Code/Dates (36)|
The end date of the event depicted in occurrence span code.
|UB1^19^00548^Occur Span End Date (33) | |UB1^15^00544^PSRO/UR Approved Stay To (89) | |UB2^8^00560^Occurrence Span Code/Dates (36)|
A quantitative value on a bill. The value is qualified by quantity type code.
|UB1^4^00533^Blood Replaced Pints (41) | |UB1^5^00534^Blood Not Replaced Pints(42) | |UB1^6^00535^Co Insurance Days (25) | |UB1^9^00538^Non Covered Days (24) | |UB1^11^00540^Number Of Grace Days (90) | |UB1^3^00532^Blood Furnished Pints Of (40) | |UB1^8^00537^Covered Days (23) | |UB2^5^00557^Non-Covered Days (8)| |UB2^4^00556^Covered Days (7)| |UB2^17^00815^Special Visit Count| |UB2^2^00554^Co-Insurance Days (9)|
A code qualifying the quantity amount information on a bill (e.g., Blood furnished, blood not replaced, blood replaced, coinsurance day, covered day, non-covered day, grace day, special visit, . . .).
A value amount qualified by value code.
|UB1^10^00539^Value Amount & Code (46-49)| |UB2^6^00558^Value Amount & Code|
A code qualifying the billing information value amount.
|UB1^10^00539^Value Amount & Code (46-49)| |UB2^6^00558^Value Amount & Code|
Class steward is Patient Administration
An alternate medical opinion rendered for an insurance certification.
The date that the second opinion was obtained.
|IN3^22^00523^Second Opinion Date|
A code that depicts the status of the second opinion.
|IN3^24^00525^Second Opinion Documentation Received| |IN3^23^00524^Second Opinion Status |
Class steward is Patient Administration
A type of insurance coverage provided to military veterans and federal workers.
A code depicting the handicapped program in which the patient is enrolled.
|IN2^65^00805^Military Handicapped Program |
A indication as to whether the champus non-avail certification is on file.
|IN2^18^00489^Champus Non-Avail Cert on File|
The date of retirement for the person covered by Champus.
|IN2^17^00488^Champus Retire Date|
The identifier of the Champus station.
|IN2^13^00484^Champus Station|
Class steward is Orders/Observation
Interested committees Information Management (Medical Records)
The information or record secured by an act or instance of viewing or noting a fact or occurrence for some health related purpose.
An indication that the observation results are abnormal.
Unique identifier for a clinical observation on a specific patient.
Rationale: primary key. Needed for establishing relationships to other classes.
OpenIssue:
This field contains the date and time of changes in the observation methods that would make values obtained from the old method not comparable with those obtained from the new method.
Rationale: alignment with V2.3
OpenIssue: This is being returned to committee to be reworked to remove the inconsistency between the name and the definition.
|OBX^12^00580^Date Last Obs Normal Values|
Indicates the type of control population against which the observation was tested for abnormalcy. control population might be age based, sex based, race based, or a generic normal range.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBX^10^00578^Nature of Abnormal Test|
This field is the clinically relevant begin date/time of the observation. In the case of observations taken directly from a subject, it is the actual date and time the observation was obtained. In the case of a specimen-associated study, this field shall represent the date and time the specimen was collected or obtained.
Rationale: This is the definition that has been developed by the committee and balloted. This is the field that is wanted in the message, not separate fields for the specimen collection time and the time of the observation. Often, an interim time is chosen as "clinically relevant". There would be too much overhead in maintaining separate fields for all the possible interim times.
|OBX^14^00582^Date/Time of the Observation|
This field is the clinically relevant end date/time of the observation. In the case of observations taken directly from a subject, it is the actual date and time the observation was obtained. In the case of a specimen-associated study, this field shall represent the date and time the specimen was collected or obtained.
Rationale: This is the definition that has been developed by the committee and balloted. This is the field that is wanted in the message, not separate fields for the specimen collection time and the time of the observation. Often, an interim time is chosen as "clinically relevant". There would be too much overhead in maintaining separate fields for all the possible interim times.
|OBX^14^00582^Date/Time of the Observation|
A code indicating the method employed in conducting the observation.
The status of the clinical result of the observation.
|OBR^25^00258^Result Status| |OBX^11^00579^Observ Result Status|
The effective date and time of the clinical result.
A sub-group identifier for the observation used to group related observations.
|OBX^13^00581^User Defined Access Checks|
Observation value.
|OBX^5^00573^Observation Value|
The degree of certainty in the clinical observation expressed as a percentage.
Rationale: closer to language used in V2.3
|OBX^9^00577^Probability|
)OR b) > lower limit (if no upper limit, e.g., >10) a) lower limit-upper limit (when both lower and upper limits are defined, e.g., for potassium 3.5 - 4.5) OR c) < upper limit (if no lower limit, e.g., <15FOR ALPHABETIC VALUES: the normal value may be reported in this location When the observation quantifies the amount of a toxic substance, then the upper limit of the range identifies the toxic limit. If the observation quantifies a drug, the lower limits identify the lower therapeutic bounds and the upper limits represent the upper therapeutic bounds above which toxic side effects are common.FOR NUMERIC VALUES
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBX^7^00575^References Range|
Indicates that the observation is a specific one of the standard narrative report components for the Universal_service_identifier. Examples: Diagnostic Impression (IMP), Gross or General Description (GDT).
Rationale: previously unmatched V2.3 field component
OpenIssue:
|OBX^3^00571^Observation Identifier|
Results-dependent codes for classifying the observation at the receiving system.
Rationale: V2.3 definition specifies that these are code
OpenIssue: Note that this is being returned to committee to be fixed.
|OBX^13^00581^User Defined Access Checks|
A qualifier of the observation value.
|OBX^2^00570^Value Type| |OM3^7^00570^Value Type|
Unit of measure in which the observation value is reported. When an observationŐs value is measured on a continuous scale, one must report the measurement units within the units field of the OBX segment. Units have a data type of CE. ISO+ abbr.
Rationale: RT: previously unmatched V2.3 field, see recommendation R037
OpenIssue:
|OBX^6^00574^Units|
Rationale: to support concept of Parent Result in OBR
OpenIssue:
Rationale: Some observations (eg. those forwarded from other institutions) may come from "Service events" of no interest to the recipient. The requirement that each observation have a Service Event should therefore be removed from the model.
Rationale: Some observations (eg. those forwarded from other institutions) may come from "Service events" of no interest to the recipient. The requirement that each observation have a Service Event should therefore be removed from the model.
OpenIssue:
Rationale: This relationship implements one of the critical business rules for this TC. A document is a construct with a single header and several observations. (Note, the relationship is optional because a document can be initially created with only the header). The Medical Records and Orders/Results TCs place great importance in the notion that the construct, observation, is shared by both groups. That is, it has the same definition when information is being retrieved for analysis and review, as it does when that information is recorded. This instance connection, to the document header allows observations to be organized for retrieval.
OpenIssue: May not have correct cardinality since there is some disagreement on the precise nature of the many-to-many connections between these two entities. This needs to be cleaned up with the general fix of the connections between the Chart_document_header and the components of the order and its observations.
Class steward is Orders/Observation
An association between a Healthcare service provider and a clinical observation.
An identifier of the clinical observation from the perspective of the associated healthcare participant.
The type of participation the provider assumes in relation to the observation.
Class steward is Orders/Observation
A report of the information or record secured by an act or instance of viewing or noting a fact or occurrence for some health related purpose.
ISSUE: consideration should be given to combining this concept with other reporting identified in the Information Management chapter.
An indicator that an acknowledgment receipt has been requested for the clinical observation report.
The reason the clinical observation result was canceled.
A unique identifier assigned to the observation result.
The reporting priority of the clinical result.
|OM1^26^00611^Reporting Priority|
The date and time the clinical observation results are issued.
Rationale: closer to language used in V2.3
|OBR^22^00255^Results Rpt/Status Chng - Date/Time|
Free form text of the observation result.
The status of the clinical observation result.
The effective date and time of the result status.
Class steward is Orders/Observation
A sample of a substance or material for examination or study (a urine specimen; a tissue specimen).
The anatomical source for the collected item.
Rationale: more specific to related component of V2.3 field
|OBR^15^00249^Specimen Source|
The site modifier for the body site from which the specimen was obtained. For example, the site could be anticubital foss, and the site modifier "right".
Rationale: required by components of V2.3 field
OpenIssue:
|OBR^15^00249^Specimen Source|
The date and time the analyzed object collection ended.
|OBR^8^00242^Observation End Date/Time|
coded modifier for the method of collection of a specimen.
Rationale: required by components of V2.3 field
OpenIssue:
|OBR^15^00249^Specimen Source|
The date and time the analyzed object is scheduled to be collected.
The date and time the analyzed object collection started.
|OBR^7^00241^Observation Date/Time|
The amount of specimen collected.
|OBR^9^00243^Collection Volume|
A description of the condition of the collected specimen.
Rationale: V2.3 field is CE datatype
|OBR^39^01030^Collector’s Comment|
A code indicating the action taken after collection of the sample (e.g., air-dried, refrigerated overnight, maintained at body heat, centrifuged immediately, maintained on ice, . . .).
Unique identifier of the analyzed object.
A description of the method used to collect the analyzed object.
Number_of_sample_containers_quantityIdentifies the number of containers for a given sample. For sample receipt verification purposes; may be different from the total number of samples which accompany the order.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^37^01028^Number Of Sample Containers|
A code depicting an additive used with the analyzed object to aid in the analysis.
Rationale: related V2.3 field component is TX datatype
|OBR^15^00249^Specimen Source|
A code depicting dangers associated with the analyzed object.
A code indicating the source of the analyzed object.
|OBR^15^00249^Specimen Source|
transport_logistics_codethe means by which a sample reaches the diagnostic service provider
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^38^01029^Transport Logistics Of Collected Sample|
Class steward is Patient Administration
A code indicating the reason the contact should be used (e.g., contact my employer if patient is unable to work).
|GT1^47^00747^Contact Reason| |IN2^54^00794^Insured’s Contact Person Reason | |IN2^51^00791^Employer Contact Reason | |IN2^57^00797^Insurance Co. Contact Reason | |NK1^29^00747^Contact Reason|
Class steward is Patient Administration
A broad categorization, based upon included procedures and diagnoses, that applies to a Healthcare event as a whole. Used for grouping and evaluating Healthcare encounters with respect to duration of care and cost.
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File>
A unique identifier assigned to the diagnostic related group.
|DG1^8^00382^Diagnostic Related Group| |DRG^1^00382^Diagnostic Related Group|
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File; Standard_Day_Stay>
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File>
<see FIN2301:DRG_Master_File>
Class steward is Orders/Observation
An authoritative direction or instruction concerning the system or course of diet for a patient.
A code identifying a special diet type for a patient.
|ODS^1^00269^Type| |PV1^38^00168^Diet Type|
Instructive description of the dietary order.
|ODS^4^00272^Text Instruction| |ODT^3^00272^Text Instruction|
A code for the type of dietary tray.
|ODT^1^00273^Tray Type|
A code identifying the service period for a diet order.
|ODS^2^00270^Service Period| |ODT^2^00270^Service Period|
An identifier of the dietary plan.
Rationale: related V2.3 field is CE datatype. this is not an identifier.
OpenIssue:
|ODS^3^00271^Diet, Supplement, or Preference Code|
Class steward is Control/Query/MasterFiles
A compound datatype containing a collection of components which together represent an address.
The components of the address datatype were influenced by the specification of the AD and XAD datatypes in the HL7 2.3 standard.
A string of text which aids in the proper routing and handling of mail.
A code depicting the type of address (e.g., current, temporary, permanent, mailing, firm/business, office, home, birth (nee), country of origin, . . .).
A identifier assigned to the census track the address is part of.
The name of the city.
The name of a country.
A code depicting the county/parish within a state/province.
Text of geographic designations in addition to state/province, country, census tract, and county. Includes bioregion and SMSA.
A code assign by a postal authority to aid in the routing and proper delivery of mail world wide.
The name (or abbreviated name) of a state of the United states or a province name.
The name of the street within the city or district (e.g., 1st street, Main street, 5th Ave., . . .).
Class steward is Control/Query/MasterFiles
A compound datatype representing a numeric amount. See the HL7 CQ and MO datatypes.
A numerical representation of an amount.
A code depicting the unit of measure for an amount (e.g., dollars, years, days, liters, grams, . . .).
|OM2^2^00627^Units of Measure| |OM4^5^00645^Container Units| |RXA^7^00349^Administered Units| |RXC^4^00316^Component Units| |RXD^5^00338^Actual Dispense Units| |RXE^11^00324^Dispense Units| |RXE^5^00320^Give Units| |RXE^24^00333^Give Rate Units| |RXG^16^00333^Give Rate Units| |RXG^7^00320^Give Units| |RXO^4^00295^Requested Give Units| |RXO^12^00303^Requested Dispense Units|
Class steward is Control/Query/MasterFiles
An attribute group for coded attributes. The contents of this attribute group is strongly influenced by the contents of the CE, ID, IS, and CF datatypes within the HL7 2.3 standard.
The code assigned to the coded concept. The combination of coding system name and assigned code text uniquely identifies the item being represented
The name of the coded concept.
The name of the coding system used.
Class steward is Control/Query/MasterFiles
A calendar date. The attributes in this attribute groups were strongly influenced by the DT and TS datatypes in the HL7 2.3 standards.
A calendar day within a month.
A month within a calendar year.
A calendar year.
Class steward is Control/Query/MasterFiles
A compound datatype representing date and time. The contents of the datetime datatype is strongly influenced by the contents of the DT, TM, and TS datatypes in the HL7 2.3 standard.
A calendar date.
A time of day.
Class steward is Control/Query/MasterFiles
Class steward is Control/Query/MasterFiles
A compound datatype for assigned identifiers. The contents of this compound datatype is strongly influenced by the specification of the EI, CX, DLN datatype in the HL7 2.3 standard.
The effective date of the identifier.
The value assigned as an identifier, often a numeric.
A check digit assigned to the identifier base upon the identification text and the check digit scheme.
A code identifying the check digit scheme used for the identifier check digit.
Date the identifier was issued.
The name of the issuing authority for the identifier.
The termination date of the identifier.
A code indicating the type of identifier.
Class steward is Control/Query/MasterFiles
A datatype representing the values yes or no. Used to indicate the presence of the condition specified by the attribute qualifier.
Class steward is Control/Query/MasterFiles
A datatype depicting a string value which captures a name an item is referred to by.
Class steward is Control/Query/MasterFiles
Class steward is Control/Query/MasterFiles
A datatype depicting a numeric values representing a percentage (fraction) of a whole.
Class steward is Control/Query/MasterFiles
A compound datatype for person name. Based upon the HL7 PN and XPN datatypes.
A person's surname or family name.
A person's given name.
An additional name between the first and last names of a person.
An additional test string added to a name. Often use to denote a degree title (e.g., MD, Ph.D., LVN, . . .) or a generation qualifier (e.g., Jr., Sr., III, . . .).
A text string preceding a person's first name usually portraying a position held by the person or a indication of the person's age/marital status. (e.g., Mr., Mrs., Miss, Sir, Reverend, General, master, . . .).
Class steward is Control/Query/MasterFiles
A compound datatype for phone numbers. Based upon the HL7 TN and XTN datatypes.
Code for a specific calling area including country and calling area within a country.
Extension to the phone number for access to beeper.
Comments about the telephone number.
A code identifying the country the phone number is within.
Code for a data or voice device used to transmit information, carry a verbal conversation or exchange information between individuals (e.g., phone, fax, modem, cellular phone, beeper, . . .).
The date the phone becomes effective.
Number that identifies a continuation or addition to the telephone number.
Number used to communicate by telephone with a person or organization.
The date the phone is no longer in effect.
A code indicating the use type of the phone (e.g., primary residence, other residence, work, vacation home, answering service, emergency, beeper, . . .).
The set of attributes which specifies the identity, amount, strength and dosage form for the drug or treatment. If the drug or treatment ordered is a compound drug/treatment OR an IV solution, and there is no Universal Service ID which represents the combination of components, this attribute type is repeated for each component.
Rationale:
OpenIssue:
Specifies information about the route of administration of the pharmacy service.
Rationale:
OpenIssue:
Class steward is Control/Query/MasterFiles
A datatype depicting a numeric value representing a count, measure, or volume of some item (as depicted by qualifiers in the attribute names).
Class steward is Control/Query/MasterFiles
A datatype depicting string data.
Class steward is Control/Query/MasterFiles
The time of day. See HL7 TM datatype.
A portion of a second.
A quantity representing the offset of the time zone from the coordinated universal time (GMT).
A hour of the day.
The minute within an hour.
The second within the minute.
Class steward is Control/Query/MasterFiles
The set of attributes which specifies the identity, amount, strength and dosage form for the drug or treatment. If the drug or treatment ordered is a compound drug/treatment OR an IV solution, and there is no Universal Service ID which represents the combination of components, this attribute type is repeated for each component.
Rationale: support use of RXC in order message
OpenIssue: Recommned using the short form class word PTcomp for this datatype
amount of the component medication to include in the treatment
Rationale: required for use of RXC with pharmacy orders
Identifier of the component substance
Rationale: required for use of RXC with pharmacy orders
OpenIssue:
The name of the medication ordered
Rationale: cannot rely on the catalog to have the medication name. May use a code such as "unknown".
OpenIssue:
strength of the medication component
Rationale: previously unmatched V2.3 field
OpenIssue:
Class steward is Control/Query/MasterFiles
specifies information about the route of administration of the pharmacy service
Rationale: support use of RXR in order message
OpenIssue: Recommned using the short form class word PTrout for this datatype
the mechanical device used to aid in the administration of the drug or other treatment
Rationale: required for use of RXR with pharmacy orders
the specific method for the administration of the drug or treatment to the patient, eg. Nebulizer, perfuse, shampoo, soak, wash, wipe.
Rationale: required for use of RXR with pharmacy orders
OpenIssue:
the route of administration, eg. Nasal, ophthalmic, perfusion, oral, sublingual.
Rationale: required for use of RXR with pharmacy orders
OpenIssue:
the site of the administration route
Rationale: required for use of RXR with pharmacy orders
OpenIssue:
Class steward is Patient Administration
An employed person.
Class steward is Patient Administration
A person or organization which employs persons.
The date the organization assumes the role of employer.
The date the organization's role as employer is terminated.
Class steward is Patient Administration
A broad categorization, based primarily upon included procedures and diagnoses, that applies to the Healthcare event as a whole. Used for grouping and evaluating Healthcare encounters with respect to duration of care and cost.
An indication that the DRG assignment has been approved by a reviewing entity.
|DG1^9^00383^DRG Approval Indicator| |DRG^3^00383^DRG Approval Indicator|
The date and time the DRG was assigned to the encounter.
|DRG^2^00769^DRG Assigned Date/Time |
An indication as to whether the DRG assigned to this encounter contains a confidential diagnosis.
|DG1^18^00767^Confidential Indicator| |DRG^10^00767^Confidential Indicator|
The amount of the encounter cost that is beyond the standard cost amount for the assigned DRG.
|DG1^13^00387^Outlier Cost| |DRG^7^00387^Outlier Cost|
A description providing additional information about the assignment of the DRG to the encounter.
A code indicating that the grouper results have been reviewed and approved.
|DG1^10^00384^DRG Grouper Review Code| |DRG^4^00384^DRG Grouper Review Code|
The version and type of the grouper used to derive the DRG.
The number of days beyond the standard day count for the assigned DRG.
|DG1^12^00386^Outlier Days| |DRG^6^00386^Outlier Days|
The portion of the total reimbursement amount designated for reimbursement of outlier days or costs.
|DRG^9^00771^Outlier Reimbursement|
A code depicting the type of outlier (day, cost) associated with the encounter DRG.
Class steward is Patient Administration
An occurrence of an event pertaining or attaching to a patient encounter.
A code depicting the incident type (e.g., body fluid exposure, equipment problem, inpatient fall, medication error, . . .).
The date and time the incident occurred.
A code depicting the potential impact of an incident on the quality of patient care.
A code depicting a classification of the incident type (e.g., preventable, user error, . . .).
Class steward is Patient Administration
An association between a Healthcare practitioner and a patient encounter.
A code depicting the role of the type of participation the healthcare practitioner assumes in the encounter.
Class steward is Patient Administration
A collection or a series of Healthcare encounters for a patient.
Episode of care descriptive text.
A code indicating the type of episode. The type code is dependent upon the reason for collection of patient encounters.
A unique identifier assigned to the episode of care.
An indication that the list of encounters associated with the episode is a closed list.
Text describing the outcome of the episode of care.
An indication that the episode represents a recurring patient service.
Class steward is Patient Administration
A charge, credit, or adjustment to charges in a patient's billing account.
An alternate description of the transaction.
|FT1^9^00363^Transaction Description - Alt|
A code depicted the location type used for billing.
|FT1^16^00133^Assigned Patient Location| |PV1^3^00133^Assigned Patient Location|
Explanatory text concerning a financial transaction.
|FT1^8^00362^Transaction Description|
The transaction amount derived from multiplying the unit amount by the number of units.
|FT1^11^00365^Transaction Amount - Extended|
A code depicting the fee schedule used for this financial transaction.
|FT1^17^00370^Fee Schedule|
The amount of the financial transaction that is applicable to the associated Healthcare benefit plan.
|FT1^15^00369^Insurance Amount|
The posting date of the financial transaction.
|FT1^5^00359^Transaction Posting Date|
transaction quantity.
|FT1^10^00364^Transaction Quantity|
A unique identifier assigned to the batch in which this transaction belongs.
|FT1^3^00357^Transaction Batch ID|
A code depicting the financial action covered in the transaction.
|FT1^7^00361^Transaction Code|
The date of the transaction.
|FT1^4^00358^Transaction Date|
A identifier assigned to the transaction for control purposes.
|FT1^2^00356^Transaction ID| |UB2^12^00564^Document Control Number|
A code depicting the transaction type (e.g., credit, charge, payment, adjustment, ...).
|FT1^6^00360^Transaction Type|
The amount associated with one transaction unit.
|FT1^12^00366^Transaction Amount - Unit|
The unit price of transaction. The cost of a single item.
|FT1^22^00374^Unit Cost|
Class steward is Patient Care
A master table of goals for a clinical pathway.
A classification code for the goal master.
A description of the goal master.
A unique identifier for the goal master.
A code indicating the interval used to calculate the next goal review date.
A code depicting the goal caregiver discipline responsible for managing the specific goal.
Class steward is Patient Administration
The person or organization assuming financial responsibility for some or all of the charges in a patient billing account.
A code depicting the classification of the financial status of the guarantor.
The combined annual income of all members of the guarantor's household.
|GT1^27^00778^Guarantor Household Annual Income|
The number of people living at the guarantor's primary residence.
|GT1^28^00779^Guarantor Household Size|
Class steward is Patient Administration
A contract held by a stakeholder which specifies the financial responsibility of the stakeholder for a patient billing account.
A indicator used to determine whether or not a system should suppress printing of the guarantor's bills.
|GT1^22^00773^Guarantor Billing Hold Flag|
A code depicting the allowable mediums for billing under this guarantor contract.
|PV2^32^00733^Billing Media Code|
A code depicting which adjustments should be made to this guarantor's charges.
|GT1^26^00777^Guarantor Charge Adjustment Code|
A code specifying the duration of the contract.
|PV1^27^00157^Contract Period|
Code identifying the type of contract entered into by the guarantor for the purpose of settling outstanding account balances.
|GT1^10^00414^Guarantor Type| |PV1^24^00154^Contract Code|
The date the guarantor contract becomes effective.
|GT1^13^00417^Guarantor Date - Begin| |PV1^25^00155^Contract Effective Date|
The rate of interest for this guarantor contract.
|PV1^28^00158^Interest Code|
Amount to be paid by the guarantor each period.
|PV1^26^00156^Contract Amount|
A code indicating the relative priority of this guarantor contract for a given patient billing account.
|GT1^15^00419^Guarantor Priority| |GT1^29^00780^Guarantor Employer ID Number|
An indication as to whether the baby in a delivery patient stay should be billed separately.
|PD1^9^00761^Separate Bill|
The date the guarantor contract is no longer in effect.
|GT1^14^00418^Guarantor Date - End|
Class steward is Patient Administration
A person or organization which is a purchaser of a health benefit plan.
Class steward is Information Management (Medical Records)
A record of health related events, facts, and related data for a particular patient.
An identifier designated for the health chart.
A classification code for the health chart (e.g., inpatient, outpatient, mental health, . . .).
The current status of the health chart.
Class steward is Information Management (Medical Records)
This class captures a record of deficiencies in the Health record. <See the class Deficiency in model MDR2300>
The date the chart deficiency was determined.
A description of the health chart discrepancy.
A code depicting the level of discrepancy found in the health chart.
A code identifying the type of deficiency identified.
Class steward is Information Management (Medical Records)
Documentation of a health related factor concerning a patient. See the class Document Header in the MDR 2300 model.
The date the document was authenticated.
A code depicting the availability of the document.
A code depicting the reason for the latest change to the document.
A code depicting the completion status of the document.
A code depicting the confidentiality status of the document.
A code indicating how the content of the document is to be presented.
The specific date that the document header was created..
The name on an electronic file containing the document.
A unique identifier assigned to the document.
The date the document was last edited.
The date the information in the document was originated.
A code depicting the storage status of the document.
The date the information in the document was transcribed.
A code depicting the document type.
Rationale: This relationship implements one of the critical business rules for this TC. A document is a construct with a single header and several observations. (Note, the relationship is optional because a document can be initially created with only the header). The Medical Records and Orders/Results TCs place great importance in the notion that the construct, observation, is shared by both groups. That is, it has the same definition when information is being retrieved for analysis and review, as it does when that information is recorded. This instance connection, to the document header allows observations to be organized for retrieval.
OpenIssue: May not have correct cardinality since there is some disagreement on the precise nature of the many-to-many connections between these two entities. This needs to be cleaned up with the general fix of the connections between the Chart_document_header and the components of the order and its observations.
OpenIssue: If we have the linkage between patient service event and healthcare chart document header right, this might not be needed as it duplicates existing connections. This is pending joint work between Information Management, Orders/Observations, and Patient Care committees.
Class steward is Patient Administration
A collection of health benefits.
A code serving as an additional refinement of an insurance plan. (e.g., standard, unified, maternity, . . .).
|IN1^31^00456^Type of Agreement Code|
An indication as to whether the insured agreed to assign the insurance benefits to the healthcare provider.
|IN1^20^00445^Assignment of Benefits|
An indication of the existence of baby coverage under the insurance plan.
|IN2^19^00490^Baby Coverage|
A description of the healthcare benefit.
An identifier for the healthcare coverage benefit plan.
|IN1^46^00471^Prior Insurance Plan ID|
The name of the benefit plan.
A code classifying the benefit plan type (e.g., commercial, Medicare, Medicaid, . . .).
|DRG^8^00770^DRG Payor| |IN1^15^00440^Plan Type|
An indication as to whether this insurance works in conjunction with other insurance plans, or if it provides independent coverage and payment of benefits regardless of other insurance that might be available to the patient.
|IN1^21^00446^Coordination of Benefits|
The deductible amount for blood.
|IN2^21^00492^Blood Deductible|
The priority sequence for an insurance plan that works in conjunction with other insurance.
|IN1^22^00447^Coord of Ben. Priority|
An indication as to whether charges for a baby should be combined with charges for the mother.
|IN2^20^00491^Combine Baby Bill|
An indication as to whether the patient has reached the copay limit.
|IN2^67^00807^Copay Limit Flag|
A code identifying the type of insurance coverage, or what type of services are covered for the purposes of a billing system.
The amount of the daily deductible for this insurance plan.
|IN2^30^00501^Daily Deductible|
The date the healthcare coverage first becomes effective.
|IN1^12^00437^Plan Effective Date|
A code depicting the source of information about the insured's eligibility for benefits (e.g., insurance company, employer, insured presented policy, insured presented card, signed statement on file, verbal information, none, . . .).
|IN2^27^00498^Eligibility Source|
The last date of service that the insurance will cover or be responsible for.
|IN1^13^00438^Plan Expiration Date|
A indication as to whether the healthcare coverage is a group contract.
A code indicating the party to which the claim should be mailed (e.g., employer, guarantor, insurance company, patient, . . .).
|IN2^5^00476^Mail Claim Party|
A code depicting the reason why a service is not covered.
|IN2^24^00495^Non-Covered Insurance Code|
An identifier of an healthcare benefit plan.
|IN1^35^00460^Company Plan Code|
The deductible amount specified by the insurance plan.
|IN1^37^00462^Policy Deductible|
The identifier for the healthcare coverage policy.
|IN1^36^00461^Policy Number|
The maximum number of days that the insurance policy will cover.
|IN1^39^00464^Policy Limit - Days|
A code depicting the extent of the coverage for a participating member (e.g., single, family, . . .).
|IN2^59^00799^Policy Scope |
A code indicating how the policy information was obtained.
|IN2^60^00800^Policy Source |
A code describing what information, if any, a provider can release about a patient.
|IN1^27^00452^Release Information Code|
A indication of whether the insurance carrier send a report of eligibility identifying the benefits the patient is eligible for.
|IN1^25^00450^Rpt of Eigibility Flag|
A rate for a given room type.
|IN2^28^00499^Room Coverage Type/Amount|
A code depicting the status of the healthcare coverage.
|IN2^16^00487^Champus Status|
The date the healthcare coverage is no longer in effect.
Class steward is Patient Administration
A level of coverage for a selected class of Healthcare services.
Description of the access protocol for the benefit service type.
An indication that the benefit service is a capitated service.
An indication that coinsurance is applicable for the benefit service.
The coinsurance percentage for the benefit service.
The copayment amount for the benefit service.
The benefit service deductible amount.
The lower coverage limit.
The payment limit on the benefit service.
An indicator that the benefit service provided by a non primary provider must have a referral from a primary care provider to be covered.
An indicator that the benefit service must be provided by a primary care provider to be covered.
A indication that the benefit service will be subject to review prior to payment.
|IN3^20^00521^Pre-Certification Req/Window|
The upper limit of the benefit coverage.
Class steward is Patient Administration
A defined level of healthcare insurance coverage.
The annual limit amount for the Healthcare coverage benefit.
A textual description of the benefit.
The name of the benefit product.
An indication as to whether the benefit includes dependent coverage.
The limit on the dependent coverage amount.
The date and time the benefit becomes effective.
The lifetime limit amount for the Healthcare coverage benefit.
The date the benefit is no longer in effect.
Class steward is Information Management (Medical Records)
Rationale: Identity of the authenticator is a key piece of information associated with a document.
OpenIssue:
Class steward is Patient Administration
Class steward is Patient Administration
An organization or person responsible for the provision of healthcare services to an individual, or involved in the provision of healthcare related services.
The type of board certification held by the healthcare provider.
An indication that the healthcare provider is board certified.
The date of certification.
The date the stakeholder assumes the role of healthcare service provider.
The unique identifier assigned to the healthcare service providers license.
The date recertification is required.
A code depicting the particular subject area or branch of medical science, as practiced by a Healthcare practitioner.
The date the stakeholder is no longer in the role of Healthcare service provider.
Class steward is Patient Administration
A role assumed by an organization stakeholder. This role issues identifiers.
The date the organization assumes the role of issuing authority for identifiers.
The date the organization is no longer in the role of issuing authority for identifiers.
Class steward is Patient Administration
A person in the role of a healthcare provider.
The name of the educational degree held by the Healthcare practitioner.
Free form text description of the healthcare practitioner.
The fellowship field of a physician.
The name of the graduate school attended by the healthcare practitioner.
The date of graduation from graduated school.
A code indicating the position of a healthcare practitioner in an healthcare organization (e.g., head of department, trainee, hospital consultant, . . .).
A code indicating the type of healthcare professional (e.g., medical doctor, nurse, pharmacist, laboratory worker, . . .).
An indication that the healthcare practitioner is a primary care provider.
The physician residency code.
Class steward is Patient Administration
A patient encounter involving an admission to an inpatient facility.
The number of actual days of an inpatient stay. The actual days quantity can not be calculated from the admission and discharge dates because of possible leaves of absence.
|PV2^11^00712^Actual Length of Inpatient Stay|
The estimated number of days in an inpatient encounter.
|PV2^10^00711^Estimated Length of Inpatient Stay|
Class steward is Patient Administration
An affirmation by an insurance company that it will pay for a specified service.
A code depicting the reason an appeal was made on a non-concur for certification.
|IN3^17^00518^Appeal Reason|
A count of the number of days for which this certification is valid.
|IN3^11^00512^Days|
The date that this certification becomes effective.
|IN3^9^00510^Certification Begin Date| |IN3^6^00507^Certification Date/Time|
A unique identifier for the certification assigned by the certification agency.
|IN3^2^00503^Certification Number|
The data and time the insurance coverage was verified.
|IN1^29^00454^Verification Date/Time|
The date/time that the certification was modified.
|IN3^7^00508^Certification Modify Date/Time|
A code depicting the denied request.
|IN3^12^00513^Non-Concur Code/Description|
The date of the non-concurrence classification.
|IN3^13^00514^Non-Concur Effective Date/Time|
The dollar amount of the penalty that will be assessed if the precertification is not performed.
|IN3^5^00506^Penalty|
The date the certification ends.
|IN3^10^00511^Certification End Date|
Class steward is Patient Administration
A person or organization which acts as a contact for insurance certifications.
A code depicting the type of certification contact. (e.g., certification agency, certification operator, approving party, physician reviewer, . . .).
Class steward is Patient Administration
A role assumed by a organization stakeholder underwriting a Healthcare benefit plan.
The date the organization assumes the role of insurer.
The date the organization is no longer in the role of insurer.
Class steward is Patient Administration
An association between a patient encounter and a location.
A code depicting the type of accommodation associated with this patient encounter.
|PV2^2^00182^Accommodation Code|
Date the association between the patient encounter and the facility location becomes effective.
A code depicting the relationship of the facility location to the patient encounter.
|FT1^16^00133^Assigned Patient Location| |PV1^42^00172^Pending Location| |PV1^6^00136^Prior Patient Location| |PV1^43^00173^Prior Temporary Location| |PV1^3^00133^Assigned Patient Location| |PV1^11^00141^Temporary Location| |PV2^1^00181^Prior Pending Location|
The status of location encounter role.
Date the association between the facility location and the patient encounter ends.
A code depicting the reason for the patient transfer.
|PV2^4^00184^Transfer Reason|
Descriptive text providing the reason for a transfer associated with the patient encounter.
A indication that use of the location has been approved.
Class steward is Orders/Observation
A test/observation service for which continuous value results are generated.
Specifies the special conditions for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the upper age limit for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the upper limit of gestational age for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the upper limit for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the lower age limit for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the lower limit of gestational age for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the lower limit for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the race or sub-species for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the gender for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the species for an absolute range (range of possible results) for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions. Results outside this range are not possible.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
The SI units of measure, when these differ from the customary units of measure
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM2^4^00629^Corresponding SI Units of Measure|
Specifies the special conditions for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the upper age limit for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the upper limit of gestational age for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the upper limit for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the lower age limit for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the lower limit of gestational age for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the lower limit for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the race or sub-species for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the gender for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
Specifies the species for a critical range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^7^00632^Critical Range for Ordinal & Continuous Obs|
The customary units of measure for a tests/observation that has numeric values
Rationale: V2.3 field is not part of an amount/UOM combination.
OpenIssue:
|OM2^2^00627^Units of Measure|
Specifies the computational method for change determination for controlling delta check warnings for numeric data. More than one delta check rule can apply.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^9^00634^Delta Check Criteria|
Specifies the change threshold information for controlling delta check warnings for numeric data. More than one delta check rule can apply
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^9^00634^Delta Check Criteria|
Specifies the high value information for controlling delta check warnings for numeric data. More than one delta check rule can apply.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^9^00634^Delta Check Criteria|
Specifies the low value information for controlling delta check warnings. More than one delta check rule can apply.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^9^00634^Delta Check Criteria|
Specifies the retention time information for controlling delta check warnings for numeric data. More than one delta check rule can apply.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^9^00634^Delta Check Criteria|
A specification of the total length and the number of decimal positions for numerically valued single observations.
Rationale: related V2.3 field is a number, not an amount
|OM2^3^00628^Range of Decimal Precision|
The smallest meaningful difference between reported values; the effective resolution of the measuring instrument or technique for continuous data, or the smallest discrete interval that can occur for discrete data.
Rationale: this is a pure number. the units are the same as for the reported values. they are not respecified here.
|OM2^10^00635^Minimum Meaningful Increments|
Specifies the special conditions for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the upper limit of age for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the upper limit of the gestation age for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the upper limit of the range for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the lower limit of age for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the lower limit of gestation age for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the low value for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the race or sub-species for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the gender for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
Specifies the species for a reference (normal) range for "numeric" observations/tests . Each reference range applies to different categories of patients according to age, sex, race, and other conditions.
Rationale: required by components of V2.3 field
OpenIssue:
|OM2^6^00631^Reference (Normal) Range - Ordinal & Continuous Ob|
A factor for converting customary units to SI units. Can be specified as an equation or a multiplier.
Rationale: related V2.3 field is TX datatype
|OM2^5^00630^SI Conversion Factor|
Class steward is Orders/Observation
A test/observation service for which categorical values results are generated.
A list of the text answers that are abnormal for the test.
Rationale: Clarity, or better representation of V2.3 element name
|OM3^5^00639^Abnormal Text/Codes for Categorical Observations|
The allowed data type for a single categorical observation.
Rationale: closer to V2.3 name
|OBX^2^00570^Value Type| |OM3^7^00570^Value Type|
A list of coded results that are critically abnormal for this observation.
Rationale: Clarity, or better representation of V2.3 element name
|OM3^6^00640^Critical Text Codes for Categorical Observations|
Normal text/codes for categorical observation.
Rationale: Clarity, or better representation of V2.3 element name
|OM3^4^00638^Normal Text/Codes for Categorical Observations|
Preferred coding system for observations whose categorical responses are taken from a specified table of codes.
|OM3^2^00636^Preferred Coding System|
a list of valid coded answers
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM3^3^00637^Valid Coded "Answers"|
Class steward is Orders/Observation
A test/observation service for which calculated results are generated.
A specification of the derivation rules for determining patient variables that are derived from one or more other patient variables.
|OM6^2^00657^Derivation Rule|
Class steward is Orders/Observation
A type of service catalog item specific to observation services.
The unique identifier assigned to the type of instrument required for the observation service type.
|OM1^13^00598^Identity of Instrument Used to Perfrom this Study|
A code depicting the permitted format of the observation value.
|OM1^3^00588^Permitted Data Types|
The usual length of time (in minutes) between the start of a test process and its completion.
Rationale: alignment of definition with V2.3. the definition specifies unit of measure to be minutes.
|OM1^24^00609^Processing Time|
An indication that a specimen is required for this observation service type.
|OM1^4^00589^Specimen Required|
The typical processing time for a single test/observation. This field indicates the time from the delivery of a specimen or transport of a patient to a diagnostic service and the completion of the study. It includes the usual waiting time. The units are measured in minutes.
Rationale: alignment of definition with V2.3. the definition specifies unit of measure to be minutes.
|OM1^23^00608^Typical Turn-Around Time|
Class steward is Orders/Observation
Condition of an observation service which may trigger the execution of another observation service.
A description of the rules that trigger reflex testing for a service catalog item.
|OM1^35^00620^Rules that Trigger Reflex Testing|
Class steward is Orders/Observation
An individual test observation, test observation battery or panel, individual medication, diet, or procedure.
one of the available priorities for performing the observation or test
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^25^00610^Processing Priority|
the available priorities for reporting the test results when the user is asked to specify the reporting priority independent of the processing priority
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^26^00611^Reporting Priority|
The service catalog item billing reference information.
information for classifying observations by the challenge component of the test, if a challenge does speciate the observation, for example, tests that include a glucose challenge.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^44^00939^Challenge Information|
A code depicting the level of confidentiality associated with the service catalog item.
|OM1^30^00615^Confidentiality Code|
The date the service catalog item is effective.
Text description of the foods, diagnosis, drugs, or other conditions that may influence the interpretation of the observation including information about the direction of the effect, and any recommendation about altering the diet, conditions, or drugs before initiating the test observation.
Rationale: alignment with V2.3 language
|OM1^32^00617^Interpretation of Observations| |OM1^39^00624^Factors that may Effect the Observation|
The service catalog fee amount.
the codes and a fixed text message that is always associated with the test described by this service catalog item
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^36^00621^Fixed Canned Message|
the modality used to classify the observations, e.g., radiograph, ultrasound, CT scan, NMR, etc. Especially important for imaging studies.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^47^00942^Modality of Imaging Measurement|
the date and time of the last change in the test procedure that would make previous results incompatible with new results, e.g., the last time that normal reference range or units changed for a numeric test/observation.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^22^00607^Effective Date/Time of Change in Test Procedure th|
contains the coding system name for the code identifying the instrument or device that is used to generate this observation or battery
Rationale: required by components of V2.3 field
OpenIssue:
|OM1^13^00598^Identity of Instrument Used to Perfrom this Study|
contains the code identifying the instrument or device that is used to generate this observation or battery
Rationale: required by components of V2.3 field
OpenIssue:
|OM1^13^00598^Identity of Instrument Used to Perfrom this Study|
the clinical information about interpreting test results. Examples are the conditions (drugs) that may cause false abnormals, and the information about the sensitivity and specificity of the test for diagnoses
Rationale: OM1/Interpretation of Observations and OM1 /Factors that may Effect the Observation contain different information.
OpenIssue:
|OM1^32^00617^Interpretation of Observations|
the underlying kind of property measured by this service catalog item. distinguishes concentrations from total amounts, molar concentrations from mass concentrations, partial pressures from colors, and so forth
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^42^00937^Kind of Quantity Observed|
contains the date and time that the last of any field change was made and in the source record corresponding to the service catalog item.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^21^00606^Date/Time Stamp for Any Change in Def Attri for Ob|
A code depicting the service catalog item method.
|OM1^14^00599^Coded Representation of Method|
A textual description of the service catalog item method.
|OM1^41^00626^Description of Test Methods|
A code used to classify the service catalog item (e.g., test battery, functional procedure or study, single test value, multiple test batteries, functional procedures as an orderable unit, single test value calculated from other independent observations, ...).
Rationale: alignment with V2.3 language
|OM1^18^00603^Nature of Test/Observation|
The expected suffixes for tests or procedures that produce a type which uses observation ID suffixes following the test/observation ID code. For example, a chest x-ray may use the suffixes IMP, REC, DEV, or others
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM5^3^00656^Observation ID Suffixes|
An indication that the service catalog item is an orderable service.
|OM1^12^00597^Orderability|
A description of special patient preparation, diet, or medications for this service catalog item.
|OM1^37^00622^Patient Preparation|
classifies this service catalog item as measuring the patient's state either at a point in time (e.g., spot urines, random urines, serum potassium), or averaged over a interval of time (e.g., concentration, total amount, or clearance over a 24-hour collection).
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^43^00938^Point Versus Interval|
An indication that a portable device may be use for the test or observation service catalog item.
|OM1^15^00600^Portable|
Free form text describing the preferred ordering method for the service catalog item.
Free form text describing the preferred scheduling method for the service catalog item.
The identifier of a medication treatment that may be needed as part of a procedure service catalog item. Examples are radioactive iodine for a thyroid screen, and methacholine for a methacholine spirometry challenge.
Rationale: V2.3 field is CE datatype
|OM1^38^00623^Procedure Medication|
defines the sort order in which this observation is presented in a standard report or display that contains the many observations
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^20^00605^Report Display Order|
A description of the credentials required for the service catalog item.
An alternate unique identifier for the service catalog item.
Rationale: specific to this usage
|OM1^7^00592^Other Test/Observation IDs for the Observation|
coding system name for an alias code/identifier for this service.
Rationale: required by components of V2.3 field
OpenIssue:
|OM1^7^00592^Other Test/Observation IDs for the Observation|
an alias code/identifier for this service.
Rationale: required by components of V2.3 field
OpenIssue:
|OM1^7^00592^Other Test/Observation IDs for the Observation|
use for which an alternate service name is created, eg. long name, short name, name for reports, report subheader.
Rationale: to retain distinction among multiple alternate names in V2.3 standard
OpenIssue:
|OM1^19^00604^Report Subheader|
An alternate name for the catalog item.
Rationale: specific to this usage
|OM1^10^00595^Preferred Short Name or Mnemonic for Observation| |OM1^8^00593^Other Names|
A code for a diagnosis or problem for which the service catalog item is a contraindication or of possible danger.
Rationale: alignment with V2.3 language
|OM1^33^00618^Contraindications to Observations|
A description of the service catalog item.
Rationale: specific to this usage
|OM1^6^00591^Observation Description|
A code indicating the maximum service interval for the service catalog item.
Rationale: alignment with V2.3 language
|OM1^40^00625^Test/Observation Performance Schedule|
The primary or preferred name of the service catalog item.
Rationale: specific to this usage
|OM1^11^00596^Preferred Long Name for the Observation| |OM1^9^00594^Preferred Report Name for the Observation|
A free form description of the service requirements for the service catalog item.
A code used to categorize the service catalog item.
formally indicates the site of the observation (to make it easy for a system to find all tests related to one anatomic site). It can be used to classify the observation by target site of the examination. For example, "heart" might be recorded as the target of the electrocardiogram, cardiac echo, and thallium exercise test.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^46^00941^Target Anatomic Site of Test|
The primary or preferred unique identifier for the service catalog item.
Rationale: alignment with V2.3 language (in general discussion of this concept)
|AIS^2^00238^Universal Service Identifier| |OBR^4^00238^Universal Service Identifier| |OBX^3^00571^Observation Identifier| |RXO^1^00292^Requested Give Code|
name of the coding system for the universal service identifier
Rationale: required by components of V2.3 field
OpenIssue:
|RXD^2^00335^Dispense/Give Code|
name for the service catalog item
Rationale: required by components of V2.3 field
OpenIssue:
|RXD^2^00335^Dispense/Give Code|
Rationale: support use of Producer ID in V2.3 OM1
OpenIssue:
Class steward is Orders/Observation
A specification of specimen requirements for test/observation service catalog items which require a specimen.
A code for the additive required for the collected specimen used in the associated observation service type.
|OM4^7^00647^Additive|
A description of the container requirements for a specimen collected for the observation service type. The description includes specification of the physical appearance, including color of tube tops, shape, and material composition (e.g., red top glass tube).
|OM4^3^00643^Container Description|
The special processing that should be applied to the container (e.g., add acidifying tablets before sending).
Rationale: differentiates this from preparation of other specimen-related items (eg. the specimen itself).
|OM4^8^00648^Preparation|
A specification of the containers volume capacity.
|OM4^4^00644^Container Volume|
A code identifying derived specimens relative to the observation service type. For some diagnostic studies the initial specimen is processed to produce results. The process also produces new "specimens" and these are studied by a second order process.
|OM4^2^00642^Derived Specimen|
The amount of specimen needed by the most specimen sparing method.
|OM4^11^00651^Minimum Collection Volume|
A specification of the normal specimen volume required. This is the amount used by the normal methods and provides enough specimens to repeat the procedure at least once.
|OM4^10^00650^Normal Collection Volume|
Special handling requirements for the collected specimen.
|OM4^9^00649^Special Handling Requirements|
The allowed priorities for obtaining the specimen.
|OM4^13^00653^Specimen Priorities|
The usual time that a specimen for this observation service type is retained after the observation is completed.
|OM4^14^00654^Specimen Retention Time|
A code identifying the specimen required by the observation service type.
Rationale: Clarity, or better representation of V2.3 element name
|OM4^6^00646^Specimen|
Class steward is Orders/Observation
An item in the formulary.
The drug enforcement agency level for the pharmacy treatment service.
The drug category code of the pharmacy treatment service.
A code depicting the formulary status of a dispensed medication.
Rationale: should be determined in the catalog, not at each dispense
A code depicting the form of the medication comprising the pharmacy treatment service.
The pharmaceutical class of the pharmacy treatment service.
A code depicting the administration route for the pharmacy treatment service.
A code depicting the therapeutic class of the pharmacy treatment service.
Rationale: link medication given to service catalog
OpenIssue:
Rationale: link medication dispensed to service catalog
OpenIssue:
Rationale: link medication on pharmacy_service_order_item to service catalog
OpenIssue:
Class steward is Patient Administration
A type of healthcare coverage provided by a state medicaid program.
A code depicting the category of aid which make this person eligible for medicaid (e.g., aged, blind, disabled, families with dependent children, ...)
An identifier assigned to a medicaid family for administration as a case.
|IN2^8^00479^Medicaid Case Number|
The date medicaid coverage becomes effective.
The date medicaid coverage terminates.
Class steward is Patient Administration
A type of Healthcare coverage provided by the federal Medicare program.
The date the person's medicare coverage becomes effective.
A code depicting the person's medicare eligibility type (e.g., age, disability, ESRD, ...).
A person's medicare coverage identifier (HICN).
|IN2^6^00477^Medicare Health Ins Card Number|
A delay prior to lifetime reserve days.
|IN1^34^00459^Delay Before L. R. Day|
The number of lifetime reserve days remaining.
|IN1^33^00458^Lifetime Reserve Days|
A code indicating the type of medicare coverage (e.g., hospital, professional,...).
A code depicting the medicare reimbursement type (e.g., GPPP Cost, GPPP Risk, PPS, ...).
A code indicating the renal status of the person's medicare coverage.
The date the person's medicare coverage is no longer in effect.
Class steward is Information Management (Medical Records)
A role of a person that authenticates the signature of a party.
The date upon which the person assumed the role of notary public.
The county in which the notary is licensed.
The state in which the notary is licensed.
Date on which the person is no longer in the role of notary public.
Class steward is Orders/Observation
An authoritative direction or instruction concerning an observation service for a patient.
Code and/or text indicating any known or suspected patient or specimen hazards.
Rationale: to capture patient hazards that would be indicated in related V2.3 field.
OpenIssue:
|OBR^12^00246^Danger Code|
Text or code describing the reason for the observation order.
Rationale: V2.3 field is CE datatype
|OBR^31^00263^Reason For Study|
Additional clinical information about the patient or specimen, such as the suspected diagnosis and clinical findings on requests for interpreted diagnostic studies.
Rationale: : better alignment with V2.3
|OBR^13^00247^Relevant Clinical Info.|
A code indicating the reporting priority of the patient service order.
A code identifying the action to be taken with respect to the specimen.
|OBR^11^00245^Specimen Action Code|
Class steward is Orders/Observation
An association between a Healthcare practitioner and an Order.
A code indicating the type of participation the Healthcare participant's assumes in connection to the order (e.g., Placer, Filler, Recipient of results, ...).
Class steward is Patient Administration
A type of stakeholder. A group of persons organized for some end or work; association. The administrative personnel or apparatus of a business.
A code that represents the type of name i.e., legal name, display name
Rationale: to support XON datatype
OpenIssue:
|IN2^70^00810^Insured Employer Organization Name And ID|
The name of an organization.
|GT1^21^00425^Guarantor Organization| |GT1^16^00420^Guarantor Employer Name| |IN1^4^00429^Insurance Company Name| |IN1^11^00436^Insured's Group Emp ID| |IN1^9^00434^Group Name| |IN2^3^00474^Insured's Employer Name| |IN2^12^00483^Champus Organization| |IN2^70^00810^Insured Employer Organization Name And ID| |IN3^18^00519^Certification Agency| |NK1^13^00202^Organization Name|
The standard industry class code of the organization.
Class steward is Information Management (Medical Records)
Rationale: Identity of the originator (is the person starting the chart - normally there is one and only one) is a key piece of information associated with a document. For reasons stated in another request, the TC would like this instance connection to be associated with an attribute of the patient care document header class.
OpenIssue:
Class steward is Patient Care
A reference table of pathway specification that are not specific to a particular patient.
A description of the clinical pathway master.
A unique identifier for a clinical pathway.
Class steward is Patient Administration
A person who may receive, is receiving, or has received Healthcare services.
Condition of a patient. (e.g., pregnant, hearing impaired, . . .).
|GT1^34^00145^Ambulatory Status| |IN2^32^00145^Ambulatory Status| |NK1^18^00145^Ambulatory Status| |PV1^15^00145^Ambulatory Status|
For newborn patients in a multiple birth the order this patient was born in.
Rationale: field is to contain the ordinal birth position, not a code for the position. V2.3 field is datatype NM.
|PID^25^00128^Birth Order|
A classifying code for patients.
|FT1^18^00148^Patient Type| |PV1^18^00148^Patient Type| |PV1^20^00150^Financial Class|
A code depicting the living arrangements of a person (e.g., Alone, Family, Relatives, Institution, . . .).
|GT1^37^00742^Living Arrangement| |IN2^35^00742^Living Arrangement| |NK1^21^00742^Living Arrangement| |PD1^2^00742^Living Arrangement|
A code depicting the nature of a dependency that may exist between one stakeholder and another.
|GT1^33^00755^Living Dependency| |IN2^31^00755^Living Dependency| |NK1^17^00755^Living Dependency| |PD1^1^00755^Living Dependency|
A indication as to whether the patient is part of a multiple birth.
|PID^24^00127^Multiple Birth Indicator|
A indication that the patient is a newborn baby.
|PV2^36^00737^Newborn Baby Indicator|
An indication that the patient is an organ donor.
|PD1^8^00760^Organ Donor|
The preferred pharmacy of the patient.
The triage classification of the patient.
Rationale: Some observations (eg. those forwarded from other institutions) may come from "Service events" of no interest to the recipient. The requirement that each observation have a Service Event should therefore be removed from the model.
OpenIssue:
Class steward is Patient Administration
The beginning of an inpatient encounter.
The date and time of the patient was admitted into an inpatient facility.
|PV1^44^00174^Admit Date/Time|
A code depicting the reason for the inpatient admission.
|PV2^3^00183^Admit Reason|
A code depicting the type of referral associated with this inpatient admission.
A code indicating the source category associated with this inpatient encounter.
|PV1^14^00144^Admit Source|
A code indicating the circumstance under which the patient was or will be admitted.
|PV1^4^00134^Admission Type|
Text describing the patient valuables left for safe keeping.
|PV2^5^00185^Patient Valuables|
An indication that pre-admission tests are required for this inpatient encounter.
|PV1^12^00142^Preadmit Test Indicator|
An indication that the inpatient encounter is a readmission.
|PV1^13^00143^Readmission Indicator|
Descriptive text identifying where valuables of patient is located.
|PV2^6^00186^Patient Valuables Location|
Class steward is Orders/Observation
An abnormal reaction of a patient to an allergen.
An identifier of the allergen which causes the allergic reaction.
|AL1^1^00203^Set ID - AL1| |AL1^3^00205^Allergy Code/Mnemonic/ Description|
An identification code for the patient condition.
|AL1^3^00205^Allergy Code/Mnemonic/ Description|
A code specifying an allergic reaction.
|AL1^5^00207^Allergy Reaction|
Free form textual description of a patient medical condition.
|AL1^5^00207^Allergy Reaction|
A code indicating the general severity of the patient condition (e.g., severe, moderate, mild, . . .).
|AL1^4^00206^Allergy Severity|
A code indicating the general allergy category (e.g., drug, food, pollen, . . .).
|AL1^2^00204^Allergy Type|
Class steward is Patient Administration
The arrival of a patient at the location of care for a patient encounter.
A code depicting the acuteness of the patients medical condition upon arrival.
The date and time of the patient arrival at the care location.
A code classifying the types of patient arrivals.
A unique identifier assigned to the medical service anticipated in the patient encounter.
A code depicting the source of arrival.
A code depicting the mode of transportation used to transport the patient to the care location.
Class steward is Patient Administration
A financial account established for a patient to track the billable amount for services received by the patient and payment made for those services.
The unique identifier of a patient account.
|BLG^3^00236^Account ID| |MRG^3^00213^Prior Patient Account Number| |PID^18^00121^Patient Account Number|
A code depicting the type of adjustment applied to the patient billing account.
|PV2^30^00731^Patient Charge Adjustment Code|
The authorization number or code received from the insurance company.
|IN1^14^00439^Authorization Information|
A code indicating the status of billing.
|IN1^32^00457^Billing Status| |PV1^41^00171^Account Status|
A indicator as to whether a certification is required.
|IN3^4^00505^Certification Required|
The current unpaid balance of a patient account.
|PV1^46^00176^Current Patient Balance|
The date the patient billing account was deleted.
|PV1^35^00165^Delete Account Date|
A code depicting the reason a patient billing account has been deleted.
|PV1^34^00164^Delete Account Indicator|
A count of the number of insurance plans expected to provide insurance coverage for this patient account.
A code indicating the expected payment source.
The date a notice of admission was sent.
|IN1^24^00449^Notice of Admission Date|
A indicator documenting whether the insurance company requires a written notice of admission.
|IN1^23^00448^Notice of Admission Flag|
A code depicting a category for the source of payment.
A reference to the unique identifier of the price schedule to be used for charges in the patient billing account.
|PV1^21^00151^Charge Price Indicator|
A code depicting the purge status of the patient billing account.
|PV2^16^00717^Purge Status Code|
The date the patient billing account was purged.
|PV2^17^00718^Purge Status Date|
The date a report of eligibility was received.
A indicator to control the purge of the patient billing account and related data.
The date authorization to bill was obtained.
|PV2^28^00729^Signature on File Date|
A code indicating a special program governing the billing account.
|PV2^18^00719^Special Program Code|
A indicator identifying whether the patient has reached the stoploss limit established in the contract master.
|IN2^68^00808^Stoploss Limit Flag|
An indicator as to whether charges should be suspended for a patient.
|IN2^66^00806^Suspend Flag|
The total amount of the adjustment made to the patient billing account.
|PV1^48^00178^Total Adjustments|
The total charge amount of the patient billing account.
|PV1^47^00177^Total Charges|
The total of the payments made on a patient billing account.
|PV1^49^00179^Total Payments|
Rationale: supports use of BLG segment in the ORM message
OpenIssue: Open issue: needs joint work with OO-PAFM
Class steward is Orders/Observation
Information about a patient, relevant to the health or treatment of that patient, that is recorded by or on behalf of a Healthcare practitioner.
ISSUE: the specializations of patient clinical items may be duplicates of information found elsewhere in the model. Of particular concern is the apparent overlap between diagnosis, patient condition, patient problem, and patient pathway problem.
The date and time the clinical state item was identified.
|AL1^6^00208^Identification Date|
An indication that the patient condition is employment related.
A unique identifier for the clinical state item.
Class steward is Orders/Observation
A stakeholder that is the source of information concerning a patient clinical item.
Class steward is Patient Administration
The act of dying; the end of life; the total and permanent cessation of all the vital functions of a patient.
The identifier assigned to the death certificate.
The date that the death certificate is recorded.
A major classification of the cause of death.
The date and time of death.
The name of the location where the death occurred.
The name of the source providing the death notification.
A code identifying the source type used for verification.
The date the death information is verified.
Name of the person providing verification of death.
Class steward is Patient Administration
The end of a inpatient encounter.
A code depicting the disposition of the patient following discharge.
|PV1^36^00166^Discharge Disposition|
The date and time that the patient is discharged from an inpatient facility.
An identifier assigned to the discharge location.
|PV1^37^00167^Discharged to Location|
A code depicting the expected disposition of the patient upon discharge.
|PV2^27^00728^Expected Discharge Disposition|
Class steward is Patient Administration
The decision reached from the process of determining by examination the nature and circumstances of a diseased condition.
The date and time the diagnosis physician attests to the validity of the diagnosis.
|DG1^19^00768^Attestation Date/Time|
A primary classification of diagnosis.
|DG1^17^00766^Diagnosis Classification|
An indication that the diagnosis is confidential.
|DG1^18^00767^Confidential Indicator| |DRG^10^00767^Confidential Indicator|
Free form description of the diagnosis.
Date and time the diagnosis was determined.
A unique identifier designating the diagnosis.
|FT1^19^00371^Diagnosis Code| |PR1^15^00772^Associated Diagnosis Code|
The date the decease indicated in the diagnosis became present in the patient.
|DG1^5^00379^Diagnosis Date/Time|
The diagnostic phase code.
The diagnosis identification code.
|DG1^2^00376^Diagnosis Coding Method|
The relative priority of the diagnosis.
|DG1^15^00389^Diagnosis/DRG Priority|
The data and time the diagnosis was ruled out.
The reason the diagnosis was ruled out.
A code depicting the severity of the diagnosis.
A classification type of diagnosis (e.g., admitting, working, discharge, . . .).
|DG1^6^00380^Diagnosis/DRG Type|
Class steward is Patient Administration
An interaction between a patient and a Healthcare participant for the purpose of providing patient services or assessing the health status of a patient.
Type of further action, if any, planned as part of the care of the patient (e.g., appointment given, appointment to be given, admission arranged, patient admitted, . . .).
A code depicting the reason for cancellation of an encounter.
A percentage of patient encounter allocated to counseling.
A textual description of the patient encounter.
|PV2^12^00713^Visit Description|
A classification of a patient encounter.
|PV2^7^00187^Visit User Code|
The date and time that the patient encounter ends.
|PV1^45^00175^Discharge Date/Time|
A count of the number of insurance plans that may provide Healthcare benefit coverage for this patient encounter.
|PV2^20^00721^Expected Number of Insurance Plans|
The date the patient first experienced a similar illness. Used to determine pre-existing conditions
|PV2^29^00730^First Similar Illness Date|
A code indicating the type of follow-up required after completion of the patient encounter.
|PV1^10^00140^Hospital Service|
A unique identifier assigned to the patient encounter.
|PV1^19^00149^Visit Number| |PV1^50^00180^Alternate Visit ID|
A classification of the patient.
|FT1^18^00148^Patient Type| |PV1^2^00132^Patient Class| |PV1^18^00148^Patient Type|
A code depicting the relative priority of the patient encounter.
|PV2^25^00726^Visit Priority Code|
A code depicting the purpose of the patient encounter.
The data and time the documentation of the patient encounter is signed.
An indication as to whether or not the patient is to be extended special courtesies.
|PV1^22^00152^Courtesy Code|
The date and time that the patient encounter begins.
A code depicting the status of the patient encounter.
|PV2^24^00725^Patient Status Code|
A code depicting the type of transportation required or arranged for the transport of the patient (e.g., stretcher, wheelchair, ambulance, taxi, . . .).
A code depicting the urgency of the patient encounter.
Class steward is Patient Administration
A release of patient information to a third party.
The data and time of the disclosure.
Free form textual description of the information disclosed.
Free form text description of the requested information.
A code indicating why information about the patient was disclosed.
Date the disclosed patient information was requested.
A code indicating the priority of the request by a requester.
Class steward is Patient Administration
A role played by the stakeholder. This role is the recipient of patient information.
Class steward is Patient Care
A Clinical pathway, or treatment plan, established for a particular patient.
The date the patient pathway was established.
A unique identifier assigned to the patient pathway.
A code depicting the life cycle states of the patient pathway (e.g., active, suspended, complete, canceled, delayed, scheduled, . . .).
The date and time the life cycle status indicated by the life cycle status code is in effect.
Class steward is Patient Care
A pathway goal specific to a particular patient.
A code used to categorize patient pathway goals.
The date/time the patient goal is initially created.
A code depicting the progress towards achievement of the goal (e.g., achieved, ahead of schedule, delayed, failed to achieve, . . .).
Comment text associated with the goal evaluation.
A unique identifier assigned to the patient pathway goal.
The effective date/time of the most recently assigned goal life cycle.
A code indicating the state of the goal (e.g., active, canceled, inactive, suspended, . . .).
A code indicating the caregiver disciplines responsible for managing a patient pathway goal.
The date/time of the next scheduled goal review.
The second most recent date/time the goal was reviewed.
The date/time of the most recent review of the patient pathway goal.
A code indication the review interval for the patient pathway goal.
A code depicting the review status of the patient pathway goal.
A code used to identify the individual or group for whom the goal has been established for the benefit of a particular patient (e.g., family group, family member, patient, . . .).
Class steward is Patient Care
A person who is the target of a pathway goal.
Class steward is Patient Care
A problem addressed by a patient pathway.
The date the patient problem is resolved.
A code used to categorize the patient problem.
A code depicting the level of verification for the patient problem (e.g., confirmed, differential, provisional, rule-out, . . .).
The estimated date and time of the patient problem resolution.
A unique identifier assigned to the patient problem.
A code depicting the current status of the problem (e.g., active, active-improving, active-stable, active-worsening, inactive, resolved, . . .).
A code depicting the caregiver discipline responsible for managing the patient problem.
A textual description of when the problem began.
The date/time the patient problem began.
An indication of the patient's family or significant other's comprehension of the actual problem/prognosis.
A textual description of the perseverance of a master problem.
A quantitative numerical representation of the certainty that the problem exist for the patient.
A indication of the patient's comprehension of the problem.
A qualitative representation of the certainty of the problem (e.g., high, medium, low, . . .).
A indication of the patient's awareness of the prognosis for the problem.
A textual description of the prognosis for a patient problem.
Prioritization of the problem (e.g., numeric ranking or the use of words such as primary, secondary, . . .).
A code depicting the level of security or sensitivity surrounding the problem.
The effective data and time of the current problem status.
Class steward is Patient Administration
The patient condition or complaint of the patient in a patient encounter.
A indication that the patient problem is an active problem.
A unique identifier of the patient's problem.
The name of the patient problem.
A prefix modifying the problem identified by the patient problem identifier.
A code depicting the severity of the patient's problem.
A prefix modifying the problem identified by the patient problem identifier.
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
An introduction of a patient from one caregiver to another caregiver or provider institution. The referral may authorize the patient to receive Healthcare services. A referral may authorize a specified quantity of a particular kind or level of service. A referral may also simply be a recommendation or introduction.
The number of authorized referral visits.
Free form text describing the referral.
Free form text providing the reason for the referral.
Class steward is Orders/Observation
The rendering of a Healthcare service to a patient.
ISSUE: Should there be an Observation Service Event specialization Patient Service Event?
The date the service provider attests that the patient service was delivered as documented.
The date attestation is due for this patient service.
Date the patient service begins.
|OBR^7^00241^Observation Date/Time| |RXA^3^00345^Date/Time Start of Administration|
Monetary amount for the charge to the ordering entitiy for the studies performed when applicable.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^23^00256^Charge To Practice|
Charge code for the charge to the ordering entitiy for the studies performed when applicable.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^23^00256^Charge To Practice|
indicates whether patient considers this procedure to be confidential.
A code depicting the type of consent that was obtained for permission to treat the patient. May not represent consent from the patient.
|PR1^13^00403^Consent Code|
An indication that the patient service was declined.
Text that describes the service performed along with relevant details of the service.
The end date and time for the patient service.
|OBR^8^00242^Observation End Date/Time| |RXA^4^00346^Date/Time End of Administration|
The patient service unique identifier This is often assigned by the filler, but may be assigned by other processes. This attribute must use the EI datatype in all messages.
|FT1^23^00217^Filler Order Number| |OBR^3^00217^Filler Order Number| |ORC^3^00217^Filler Order Number| |TXA^15^00217^Filler Order Number|
Status of the fulfillment of an order. This status is originated by the filler. This is different from the status of the order itself, which is represented by ORC/ Order Control. This is NOT a trigger event.
Rationale: represents the ORC order control code, not the ORC Order Status (status of order fulfillment by the filler).
OpenIssue:
|ORC^5^00219^Order Status|
Indicates the date and time that a status, as defined in Order Status, is entered or changed. Note: Order Status represents the status of order fulfillment by the filler. This is different from Order Control Code, which reflects the status of the order from the placer's viewpoint.
Rationale: to represent the use of this V2.3 field as the date and time of change in ORC/ order status.
OpenIssue:
|OBR^22^00255^Results Rpt/Status Chng - Date/Time|
A code indicating a recurring service and the nature of the recursion.
|PV2^31^00732^Recurring Service Code|
Status of results for this event.
Rationale: alignment with V2.3 name. missing definition in RIM08.
OpenIssue:
|OBR^25^00258^Result Status|
The date the patient service is scheduled to begin.
|OBR^36^00268^Scheduled Date/Time|
A description of the service event.
Rationale: Some observations (eg. those forwarded from other institutions) may come from "Service events" of no interest to the recipient. The requirement that each observation have a Service Event should therefore be removed from the model.
Rationale: support references to facilities in OBR; the parts of a pharmacy_service_event may be performed at several locations, which will be represented by relationships from each of the parts.
Class steward is Patient Administration
A place where patient services are delivered.
Address of the location.
Closing date of the location.
optional freetext description of the location
Rationale: previously unmatched V2.3 field
OpenIssue:
|LOC^2^00944^Location Description|
the e-mail address for the patient location, if any.
Rationale: required by components of V2.3 field (XTN datatype)
OpenIssue: this is not a location oriented data item
|LOC^6^00949^Location Phone|
A unique identifier of a patient care location.
|NPU^1^00209^Bed Location| |PV1^39^00169^Servicing Facility| |RXA^11^00353^Administered-at Location| |RXD^13^00299^Dispense/deliver-to Location| |RXE^8^00299^Dispense/deliver-to Location| |RXG^11^00299^Dispense/deliver-to Location| |RXO^8^00299^Dispense/deliver-to Location|
The number of licensed beds at the location.
name of the location.
Opening date of the location.
Phone at the location.
The specialty code of the service.
A code indicating the status of the location.
A code indicating the type of patient care location (e.g., hospital, clinic, hospital ward, room, bed, . . .).
Rationale: previously unmatched V2.3 field
OpenIssue:
Rationale: specify location for individual dispenses
OpenIssue:
Rationale: specify dispense location for individual give notices
OpenIssue:
Rationale:
OpenIssue: Orders committee asked for this to be connected to the class "Patient_service_order_revision", but there is no such class in the model.
Rationale: support references to facilities in OBR; the parts of a pharmacy_service_event may be performed at several locations, which will be represented by relationships from each of the parts.
Class steward is Orders/Observation
An authoritative direction or instruction concerning Healthcare services for a patient.
A code identifying someone or something other than the patient to be billed for this service.
|BLG^2^00235^Charge Type|
Telephone number to call for clarification of request or other information regarding the order
Rationale: previously unmatched V2.3 field
OpenIssue:
|ORC^14^00228^Call Back Phone Number|
A code depicting a condition that when satisfied should end the series of service orders.
Identifier of the physical device (terminal,PC) used to enter the order
Rationale: previously unmatched V2.3 field
OpenIssue:
|ORC^18^00232^Entering Device|
an indicator that the patient needs to be escorted to the diagnostic service department. Note: The nature of the escort requirements is captured in another attribute.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^42^01033^Escort Required|
This attribute must use the EI datatype in all messages.
Rationale: these are alternate keys to the class
OpenIssue:
|FT1^23^00217^Filler Order Number| |OBR^3^00217^Filler Order Number| |ORC^3^00217^Filler Order Number| |TXA^15^00217^Filler Order Number|
A code indicating the status of the patient service order.
Rationale: ORC/Order Control and OBR/Order Status need separate representation in the RIM. This RIM08 attribute was selected to represent the ORC field, and renamed accordingly.
OpenIssue: should this name remain "status", or should the description be changed?
|ORC^1^00215^Order Control|
Explanation (either in coded or text form) of the reason for the order event.
Rationale: previously unmatched V2.3 field
OpenIssue:
|ORC^16^00230^Order Control Code Reason|
Date/time that the changes to the order took effect or are suppossed to take effect
Rationale: previously unmatched V2.3 field
OpenIssue:
|ORC^15^00229^Order Effective Date/Time|
A composite identifier of a service order. Including the order id and the ordering application. Allows an order placing application to group sets of orders together and subsequently identify them. This attribute must use the EI datatype in all messages.
Rationale: previously unmatched V2.3 field
|ORC^4^00218^Placer Group Number|
A unique identifier for the patient service order.
|FT1^23^00217^Filler Order Number| |OBR^3^00217^Filler Order Number| |OBR^2^00216^Placer Order Number| |ORC^3^00217^Filler Order Number| |ORC^2^00216^Placer Order Number| |TXA^15^00217^Filler Order Number| |TXA^14^00216^Placer Order Number|
The date the order was placed.
|ORC^9^00223^Date/Time of Transaction|
A means of specifying when the service described by the order segment is to be performed and how frequently. It is a complex multicomponent field that can have repeats. If a specimen is required for the order, the Priority component contains specimen collection priority rather than processing priority)
Rationale:
OpenIssue:
This attribute must use the EI datatype in all messages.
Rationale: these are alternate keys to the class. renamed to match definition
OpenIssue:
|OBR^2^00216^Placer Order Number| |ORC^2^00216^Placer Order Number| |TXA^14^00216^Placer Order Number|
code or free text comments on special requirements for the transport of the patient to the diagnostic service department
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^43^01034^Planned Patient Transport Comment|
A phone number to be used to report results from the service order.
Rationale: to differente this attribute from ORC/Call Back phone number, which has a different meaning both from this attribute, and from this attribute's related V2.3 field: OBR/ order callback phone.
|OBR^17^00250^Order Callback Phone Number| |ORC^14^00228^Call Back Phone Number|
A code used to allow the placer application to determine the amount of information to be returned from the filler.
|ORC^6^00220^Response Flag|
Body site where service is to be performed. Example sites are ears, arm, eye.
Rationale: previously unmatched usage for V2.3 field
OpenIssue:
|OBR^15^00249^Specimen Source|
Site modifier describing the site where the service should be performed. For example, the site could be anticubital foss, and the site modifier "right."
Rationale: previously unmatched usage for V2.3 field
OpenIssue:
|OBR^15^00249^Specimen Source|
Source name or code describing the site where the service should be performed. Example coded values are abscess, blood arterial, blood bag, burn, dose med or blood, ear, filter, gastric fluid, marrow, patient, tissue, urine
Rationale: previously unmatched usage for V2.3 field
OpenIssue: need to make the description a little bit clearer.
|OBR^26^00259^Parent Result|
indicator of whether transport arrangements are known to have been made.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^41^01032^Transport Arranged|
An indicator of who is responsible for arranging transport of the patient to the planned diagnostic service. Examples: Requester, Provider, Patient
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^40^01031^Transport Arrangement Responsibility|
A code indicating how (or whether) to transport a patient.
|OBR^30^00262^Transportation Mode|
Date & time to charge for the ordered service.
Rationale: required by components of V2.3 field
OpenIssue:
|BLG^1^00234^When to Charge|
A code determining the timing of billing the charges associated with the order service item.
Rationale: alignment with V2.3 component datatype
|BLG^1^00234^When to Charge|
OpenIssue: If we have the linkage between patient service event and healthcare chart document header right, this might not be needed as it duplicates existing connections. This is pending joint work between Information Management, Orders/Observations, and Patient Care committees.
Rationale: previously unmatched V2.3 field
OpenIssue:
Rationale: to support concept of Parent Result in OBR
OpenIssue:
Rationale: supports use of BLG segment in the ORM message
OpenIssue: Open issue: needs joint work with OO-PAFM
Class steward is Patient Administration
A type of stakeholder. An individual human being.
The date and time of a person's birth.
|GT1^8^00412^Guarantor Date/Time of Birth| |IN1^18^00443^Insured's Date of Birth| |NK1^16^00110^Date/Time of Birth| |PID^7^00110^Date/Time of Birth| |STF^6^00110^Date/Time of Birth|
The place the person was born.
|PID^23^00126^Birth Place|
The current citizenship of a person.
|GT1^35^00129^Citizenship| |IN2^33^00129^Citizenship| |NK1^19^00129^Citizenship| |PID^26^00129^Citizenship|
A code depicting the nature of publicity protections in place for this person.
|GT1^38^00743^Publicity Indicator| |GT1^39^00744^Protection Indicator| |IN2^36^00743^Publicity Indicator| |IN2^37^00744^Protection Indicator| |NK1^23^00744^Protection Indicator| |NK1^22^00743^Publicity Indicator| |PV2^21^00722^Visit Publicity Code|
The date and time that a person's death occurred.
|GT1^24^00775^Guarantor Death Date And Time| |PID^29^00740^Patient Death Date and Time|
A indication that the person is dead.
|GT1^25^00776^Guarantor Death Flag|
A code identifying a person disability.
|GT1^52^00753^Handicap| |IN1^48^00753^Handicap| |NK1^36^00753^Handicap| |PD1^6^00753^Handicap|
The amount of education a person achieved.
The ethnic group of the person.
|GT1^44^00125^Ethnic Group| |IN2^42^00125^Ethnic Group| |NK1^28^00125^Ethnic Group| |PID^22^00125^Ethnic Group|
A code depicting the gender (sex) of a person.
|GT1^9^00413^Guarantor Sex| |IN1^43^00468^Insured's Sex| |NK1^15^00111^Sex| |PID^8^00111^Sex| |STF^5^00111^Sex|
A code identifying a language.
|GT1^36^00118^Primary Language| |IN2^34^00118^Primary Language| |NK1^20^00118^Primary Language| |PID^15^00118^Primary Language|
A code depicting the marital status of a person.
|GT1^30^00781^Guarantor Marital Status Code| |IN2^43^00119^Marital Status| |NK1^14^00119^Marital Status| |PID^16^00119^Marital Status| |STF^17^00119^Marital Status|
A person's military branch of service.
|IN2^14^00485^Champus Service|
The name of a person's military rank.
|IN2^15^00486^Champus Rank/Grade|
The military status of a person.
|PID^27^00130^Veterans Military Status|
A code depicting the nationality of a person.
|GT1^43^00739^Nationality| |IN2^41^00739^Nationality| |NK1^27^00739^Nationality| |PID^28^00739^Nationality|
An indication of the representation of the primary name. This attriubute does not necessarily specify the character sets used. Current codes are defined for Ideographic, Alphabetic, Phonetic.
Rationale: required by components of V2.3 field
OpenIssue:
|GT1^3^00407^Guarantor Name|
Represents the type of name, eg. Alias, Legal, Display ...
Rationale: required by components of V2.3 field
OpenIssue:
|PID^5^00108^Patient Name|
The primary name of a person.
|DG1^16^00390^Diagnosing Clinician| |GT1^4^00408^Guarantor Spouse Name| |GT1^3^00407^Guarantor Name| |GT1^45^00748^Contact Person Name| |IN1^6^00431^Insurance Co. Contact Ppers| |IN1^16^00441^Name of Insured| |IN2^52^00792^Insured’s Contact Person’s Name| |IN2^49^00789^Employer Contact Person Name| |IN2^23^00494^Special Coverage Approval Title| |IN2^9^00480^Champus Sponsor Name| |IN3^21^00522^Case Manager| |IN3^8^00509^Operator| |IN3^14^00515^Physician Reviewer| |IN3^25^00526^Second Opinion Physician| |IN3^15^00516^Certification Contact| |IN3^3^00504^Certified By| |NK1^2^00191^Name| |NK1^30^00748^Contact Person Name| |PID^5^00108^Patient Name|
A code depicting the race of a person.
|IN2^71^00113^Race| |NK1^35^00113^Race| |PID^10^00113^Race|
A person's religious preference.
|GT1^41^00120^Religion| |IN2^39^00120^Religion| |NK1^25^00120^Religion| |PID^17^00120^Religion|
An indicator that the person is a student.
|GT1^40^00745^Student Indicator| |IN2^38^00745^Student Indicator| |NK1^24^00745^Student Indicator| |PD1^5^00745^Student Indicator|
And indication that the person is an VIP.
|PV1^16^00146^VIP Indicator|
Class steward is Patient Administration
A additional name by which a person is or has been known.
The effective date of the person's alternate name.
An indication of the representation of the person's name. This attriubute does not necessarily specify the character sets used. Current codes are defined for Ideographic, Alphabetic, Phonetic.
Rationale: required by components of V2.3 field
OpenIssue: may be part of an attribute type mapping to a compound datatype
|PID^6^00109^Mother's Maiden Name|
Other names by which a person is known.
|GT1^36^00118^Primary Language| |GT1^42^00746^Mother’s Maiden Name| |IN2^34^00118^Primary Language| |IN2^40^00746^Mother’s Maiden Name| |IN2^7^00478^Medicaid Case Name| |NK1^20^00118^Primary Language| |NK1^26^00746^Mother’s Maiden Name| |PID^15^00118^Primary Language|
A code indicating the reason the alternate person name is used.
The termination date of the person's alternate name.
A code indicating the type of alternate name (e.g., nickname, alias, maiden name, legal, adopted, . . .).
Class steward is Patient Administration
The act or process of bearing or bringing forth offspring.
An indication that the baby in a person birth event is detained after the mother's discharge.
|PV2^37^00738^Baby Detained Indicator|
A unique identifier assigned to a person's birth certificate.
The name of the city the birth took place in.
A code depicting the country the birth occurred in.
A code depicting the method of birth (e.g., cesarian, vaginal, forceps, . . .).
The ordinal position the person is born in a multiple-birth birth event.
|PID^25^00128^Birth Order|
The county in which the person's birth record is recorded.
The date the birth event was recorded.
The state or province in which the birth event took place.
The delivery date of the birth event.
|NK1^16^00110^Date/Time of Birth| |PID^7^00110^Date/Time of Birth| |STF^6^00110^Date/Time of Birth|
An indication that the birth was a multiple birth event.
|PID^24^00127^Multiple Birth Indicator|
The number of days in a patient encounter in which there is a person birth event that is allocated to the newborn.
An indication that the baby in the birth event was stillborn.
Class steward is Patient Administration
The state of being employed. An occupation by which a person earns a living; work; business.
address of the person's work site.
The date the person's employment begins.
|GT1^31^00782^Guarantor Hire Effective Date| |IN2^44^00787^Employment Start Date|
The type of hazards a person is exposed to in their employment.
A code depicting the job classification used by the employer for the job related to the person employment.
|GT1^50^00786^Job Code/Class| |IN2^47^00786^Job Code/Class| |NK1^11^00200^Next of Kin Job/Associated Parties Code/Class| |STF^19^00786^Job Code/Class|
The title of the job held.
|GT1^49^00785^Job Title| |IN2^46^00785^Job Title| |IN2^22^00493^Special Coverage Approval Name| |NK1^10^00199^Next of Kin/Associated Parties Job Title| |STF^18^00785^Job Title|
The telephone number of a person at the persons place of service.
|PID^14^00117^Phone Number - Business|
Protective equipment needed for employment.
A person's salary amount.
A salary type (e.g., hourly, annual, commission, . . .).
A code depicting the status of the person's employment.
|GT1^20^00424^Guarantor Employment Status| |GT1^53^00752^Job Status| |IN1^42^00467^Insured's Employment Status| |IN2^48^00752^Job Status| |NK1^34^00752^Job Status|
Date the person's employment ends.
|GT1^32^00783^Employment Stop Date| |IN2^45^00783^Employment Stop Date|
Class steward is Patient Administration
An authorization for patient services by a third party prior to the delivery of the patient service.
The number of authorized encounters.
The date the authorized period begins.
The end date of the authorized period.
A unique identifier assigned to the pre authorization.
The date and time the pre authorization is issued.
The date and time the preauthorization was created.
A description of restrictions associated with the preauthorization.
A code depicting the status of a preauthorization.
The date and time of the last status change.
Class steward is Patient Administration
Class steward is Patient Care
A master file of problems for which clinical pathways are developed.
A classification code for the problem master.
A description of the problem master.
A unique identifier for the problem master.
A code for a default caregiver discipline responsible for managing the problem.
The default perseverance of a master problem.
Class steward is Orders/Observation
A therapeutic or diagnostic intervention employed in response to a patient condition.
A code identifying the anaesthesia used in a procedure.
|PR1^9^00399^Anesthesia Code|
A count of the anesthesia minutes involved in the procedure.
|PR1^10^00400^Anesthesia Minutes|
The reason for delay of the surgery patient service.
The data and time of the closing incision of the surgery patient service.
The data and time of the opening incision of the surgery patient service.
A number indicating the relative priority of the procedure to all other procedures provided in this encounter.
|PR1^14^00404^Procedure Priority|
A code used to identify a procedure.
|FT1^25^00393^Procedure Code| |PR1^3^00393^Procedure Code|
The date/time of the procedure.
|PR1^5^00395^Procedure Date/Time|
A code identifying the functional type of the procedure.
|PR1^6^00396^Procedure Type|
The length of the procedure, measured in minutes.
|PR1^7^00397^Procedure Minutes|
Class steward is Patient Administration
The person or organization responsible for applying the service catalog item to the patient.
Rationale: support use of Producer ID in V2.3 OM1
OpenIssue:
field permits the sorting of observation orders and values by the providing service's department/section. The codes for this field should be taken from ASTM Table 15 (Diagnostic Service Codes)
Rationale: previously unmatched V2.3 field
OpenIssue:
|OM1^16^00601^Observation Producing Department/Section|
Rationale: support use of Producer ID in V2.3 OM1
OpenIssue:
Class steward is Information Management (Medical Records)
Rationale: Identity of the receiver is a key piece of information associated with a document. For reasons stated in another request, the TC would like this instance connection to be associated with an attribute of the patient care document header class.
OpenIssue:
Class steward is Patient Administration
An undesirable or unfortunate happening that occurs unintentionally and usually results in harm, injury, damage, or loss.
An indication that the accident resulted in death.
Rationale: specific to this usage; alignment with V2.3 language
|ACC^6^00814^Accident Death Indicator|
Free form textual description of the accident.
The date and time the accident occurred.
Rationale: alignment with V2.3 language
|ACC^1^00527^Accident Date/Time|
A description of the location of the accident.
Rationale: specific to this usage
|ACC^3^00529^Accident Location|
The state in which the accident occurred.
Rationale: state is a location (don't need both location and state in the name); specific to this usage
|ACC^4^00812^Auto Accident State|
A code depicting the type of accident.
|ACC^2^00528^Accident Code|
An indication that the accident is work related.
Rationale: as modeled, this is a characteristic of the accident, which is not the same as an injury.
|ACC^5^00813^Accident Job Related Indicator|
Class steward is Orders/Observation
An association between a healthcare service provider and a patient service event.
A code depicting the type of participation the healthcare service provider has in the patient service event.
Class steward is Orders/Observation
An association between an analyzed object and a service event.
A code depicting the action taken upon the analyzed object in the context of a service event.
The data and time the specimen was received for use in the service event.
|OBR^14^00248^Specimen Received Date/Time|
Class steward is Patient Administration
A person or organization that has an investment, share, or interest in healthcare.
The address of a stakeholder.
|GT1^17^00421^Guarantor Employer Address| |GT1^5^00409^Guarantor Address| |IN1^5^00430^Insurance Company Address| |IN1^44^00469^Insured's Employer Address| |IN1^19^00444^Insured's Address| |NK1^4^00193^Address| |OM1^28^00613^Address of Outside Site(s)| |PID^11^00114^Patient Address| |PID^12^00115^County Code|
A code depicting the credit rating of a stakeholder.
|GT1^23^00774^Guarantor Credit Rating Code| |PV1^23^00153^Credit Rating|
The email address of a stakeholder.
The phone number of a stakeholder.
|GT1^18^00422^Guarantor Employ Phone Number| |GT1^6^00410^Guarantor Ph Num- Home| |GT1^7^00411^Guarantor Ph Num-Business| |GT1^46^00749^Contact Person’s Telephone Number| |IN1^7^00432^Insurance Co Phone Number| |IN2^50^00790^Employer Contact Person Phone Number| |IN2^53^00793^Insured’s Contact Person Telephone Number| |IN2^58^00798^Insurance Co Contact Phone Number| |IN2^63^00803^Insured’s Telephone Number - Home| |IN2^64^00804^Insured’s Employer Telephone Number| |IN3^16^00517^Certification Contact Phone Number| |IN3^19^00520^Certification Agency Phone Number| |NK1^6^00195^Business Phone Number| |NK1^31^00749^Contact Person’s Telephone Number| |OM1^17^00602^Telephone Number of Section| |OM1^29^00614^Phone Number of Outside Site| |PID^13^00116^Phone Number - Home|
A code depicting the type of stakeholder (e.g., person, organization, . . .).
Class steward is Patient Administration
A person or organization which has an affiliation with another stakeholder.
A code indicating the familiar relationship that exist between the affiliated [person-]stakeholders (e.g., brother, sister, parent, spouse, . . .).
|GT1^11^00415^Guarantor Relationship| |GT1^48^00784^Contact Relationship Code| |IN1^17^00442^Insured's Relationship to Patient| |IN2^62^00802^Guarantor’s Relationship To Insured| |IN2^72^00811^HCFA Patient Relationship to Insured| |NK1^3^00192^Relationship|
Class steward is Patient Administration
A association between one stakeholder and another.
A code indicating the nature of the affiliation between the associated stakeholders (e.g., employer, emergency contact, next of kin, . . .).
|GT1^11^00415^Guarantor Relationship| |IN2^11^00482^Dependent of Champus Recipient| |NK1^7^00196^Contact Role|
Description of the stakeholder affiliation.
The date the affiliation between the associated stakeholders begins.
|IN2^55^00795^Relationship To The Patient Start Date| |NK1^8^00197^Start Date|
The date the affiliation between the associated stakeholders ends.
|IN2^56^00796^Relationship To The Patient Stop Date| |NK1^9^00198^End Date|
Class steward is Patient Administration
A unique identifier assigned to a person or organization.
The effective date of the identifier.
A unique identifier assigned to a stakeholder.
|FT1^21^00373^Ordered By Code| |FT1^20^00372^Performed By Code| |FT1^13^00367^Department Code| |FT1^24^00765^Entered By Code| |GT1^2^00406^Guarantor Number| |GT1^12^00416^Guarantor SSN| |GT1^19^00423^Guarantor Employee ID Number| |GT1^29^00780^Guarantor Employer ID Number| |IN1^8^00433^Group Number| |IN1^3^00428^Insurance Company ID| |IN1^10^00435^Insured's Group Emp Name| |IN2^4^00475^Employer Information Data| |IN2^1^00472^Insured's Employee ID| |IN2^25^00496^Payor ID| |IN2^10^00481^Champus ID Number| |IN2^70^00810^Insured Employer Organization Name And ID| |IN2^26^00497^Payor Subscriber ID| |IN2^2^00473^Insured's Social Security Number| |IN2^61^00801^Patient Member Number| |MRG^1^00211^Prior Patient ID - Internal| |MRG^2^00212^Prior Alternate Patient ID| |MRG^4^00214^Prior Patient ID - External| |NK1^1^00190^Set ID - NK1| |NK1^12^00201^Next of Kin/Associated Parties Employee Number| |OBR^16^00226^Ordering Provider| |OBR^28^00260^Result Copies To| |OBR^32^00264^Principal Result Interpreter| |OBR^34^00266^Technician| |OBR^35^00267^Transcriptionist| |OBR^10^00244^Collector Identifier| |OBR^33^00265^Assistant Result Interpreter| |OBX^16^00584^Responsible Observer| |OBX^15^00583^Producer's ID| |OM1^5^00590^Producer ID| |ORC^10^00224^Entered By| |ORC^19^00233^Action By| |ORC^11^00225^Verified By| |ORC^12^00226^Ordering Provider| |ORC^17^00231^Entering Organization| |PID^20^00123^Driver's License| |PID^19^00122^SSN Number - Patient| |PID^2^00105^Patient ID (External ID)| |PID^3^00106^Patient ID (Internal ID)| |PID^6^00109^Mother's Maiden Name| |PID^4^00107^Alternate Patient ID - PID| |PR1^12^00402^Procedure Practitioner| |PV1^31^00161^Bad Debt Agency Code| |RXA^10^00352^Administering Provider| |RXD^10^00341^Dispensing Provider| |RXE^13^00305^Ordering Provider's DEA Number| |RXE^14^00306^Pharmacist Verifier ID| |RXO^14^00305^Ordering Provider's DEA Number| |RXO^15^00306^Pharmacist Verifier ID| |STF^22^00123^Driver's License|
name of the facility responsible for assigning a particular stakeholder identifier
Rationale: required by components of V2.3 field
OpenIssue:
|DG1^16^00390^Diagnosing Clinician|
Universal Identifier (UID) for the stakeholder identifier assigning facility.
Rationale: required by components of V2.3 field
OpenIssue:
|IN3^8^00509^Operator|
The one of the specifically enumerated schemes for constructing UIDŐs to which the UID for the assigning facility for the stankholder identifier belongs. The UID must follow the syntactic rules of the particular universal identifier scheme (defined by the UID type).
Rationale: required by components of V2.3 field
OpenIssue:
|IN3^3^00504^Certified By|
A check digit assigned to the identifier based upon the identification text and the check digit scheme.
A code identifying the check digit scheme used for the identifier check digit.
name of the coding system for a particular stakeholder identifier
Rationale: required by components of V2.3 field
OpenIssue:
|FT1^13^00367^Department Code|
User defined table which is the source for the stakeholder identifier.
Rationale: required by components of V2.3 field
OpenIssue:
|DG1^16^00390^Diagnosing Clinician|
A code identifying the type of identifier.
Date the identifier is issued.
information used to limit the applicability of a stakeholder identifier, such as the state or province in which the identifier is valid.
Rationale: required by components of V2.3 field
OpenIssue:
|PRA^6^00690^Practitioner ID Numbers|
User defined table which is the source for the stakeholder identifier.
Rationale: required by components of V2.3 field
OpenIssue:
|PV1^8^00138^Referring Doctor|
The date the identification is no longer in effect.
Class steward is Information Management (Medical Records)
This field identifies the person transcribing the document. This is a conditional value; it is required on all transcribed documents.
Rationale: TXA - 11(00924)
OpenIssue:
Class steward is Orders/Observation
Actual route of the administration of medication as part of a pharmacy treatment.
Specification for one component of the administered medication or treatment.
Rationale:
OpenIssue:
|RXC^4^00316^Component Units|
The device used to administer the medication.
|RXR^3^00311^Administration Device|
The rate at which this medication was administered.
Rationale: V2.3 field is ST datatype; Steward agreed that "rate" is a better understood term than "per_time_unit".
|RXA^12^00354^Administered Per (Time Unit)|
If the order is for a continuous administration (such as an IV), and the rate is changed at a certain time after the start, a new pharmacy service administration is created when the rate changes. This field records the time the rate was changed.
Rationale: to record begin times of individual administrations during a service event
OpenIssue:
|RXA^3^00345^Date/Time Start of Administration|
A count of the number of times the medication is administered.
Rationale: removes possible misinterpretation as quantity administered.
|RXA^2^00344^Administration Sub-ID Counter|
The date and time the medication administration ended. If null, the administration is assumed to be of no material length (ie. date/time start of administration is assumed to be date/time end of administration as well).
Rationale: to record ending times of individual administrations during a service event
OpenIssue:
|RXA^4^00346^Date/Time End of Administration|
Status of treatment administration event
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^20^01223^Completion Status|
This field contains the identifier of the condition or problem for which the drug/treatment was prescribed.
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^19^01123^Indication| |RXD^21^01123^Indication| |RXG^22^01123^Indication| |RXO^20^01123^Indication|
Free text notes from the provider administering the medication.
Rationale: CE datatype in V2.3. alignment with V2.3 language. administration notes appears in two different V2.3 segments, with different meanings. this naming differentiates between the two meanings.
|RXA^9^00351^Administration Notes| |RXG^9^00351^Administration Notes|
the expiration date of the medical substance
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^16^01130^Substance Expiration Date| |RXD^19^01130^Substance Expiration Date| |RXG^20^01130^Substance Expiration Date|
This field contains the lot number of the medical substance.
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^15^01129^Substance Lot Number| |RXD^18^01129^Substance Lot Number| |RXG^19^01129^Substance Lot Number|
This field contains the manufacturer of the medical substance administered
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^17^01131^Substance Manufacturer Name| |RXD^20^01131^Substance Manufacturer Name| |RXG^21^01131^Substance Manufacturer Name|
This field contains the reason the patient refused the medical substance. Any entry in the field indicates that the patient did not take the substance
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^18^01136^Substance Refusal Reason|
A code indicating the medication was a substitution for the one ordered.
Date/time the administration information was entered into the source system. This field is used to detect instances where treatment administration information is inadvertently entered multiple times by providing a unique identification field. Under usual circumstances, this field would be provided automatically by the computer system rather than being entered by a person
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^22^01225^System Entry Date/Time|
Rationale: link medication given to service catalog
OpenIssue:
Class steward is Orders/Observation
Notification of a pharmacy treatment dispense.
A count of the number of times the medication was dispensed.
Rationale: removes possible misinterpretation as quantity dispensed
|RXD^1^00334^Dispense Sub-ID| |RXG^2^00334^Dispense Sub-ID|
Free form text notes to the person dispensing the medication .
Rationale: alignment with V2.3 language; althouth V2.3 field is CE datatype, CE no longer supports free text in V3.0
|RXD^9^00340^Dispense Notes|
the method by which treatment is dispensed, eg. Traditional, unit-dose, floor stock, automatic dispensing
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXD^24^01222^Dispense Package Method| |RXE^30^01222^Dispense Package Method|
This field contains the size of package to be dispensed
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXD^22^01220^Dispense Package Size| |RXE^28^01220^Dispense Package Size|
Specification for one component of the dispensed medication or treatment.
Rationale:
OpenIssue:
|RXC^4^00316^Component Units|
Specification for one route of administration for the dispensed medication or treatment. Specification includes route, site, administration device and administration method.
Rationale:
OpenIssue:
|RXR^3^00311^Administration Device|
The date and time the medication is dispensed.
|RXD^3^00336^Date/Time Dispensed|
This field contains the identifier of the condition or problem for which the drug/treatment was prescribed.
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^19^01123^Indication| |RXD^21^01123^Indication| |RXG^22^01123^Indication| |RXO^20^01123^Indication|
An indicator that the pharmacist filling the order needs to pay special attention to provider instructions.
|RXD^14^00307^Needs Human Review| |RXE^20^00307^Needs Human Review| |RXG^12^00307^Needs Human Review| |RXO^16^00307^Needs Human Review|
Free form text describing the reason the medication dispensement was rejected.
Expiration date of the medication.
Rationale: alignment with V2.3 language
This field contains the lot number of the medical substance.
Rationale: alignment with V2.3
|RXA^15^01129^Substance Lot Number| |RXD^18^01129^Substance Lot Number| |RXG^19^01129^Substance Lot Number|
This field contains the manufacturer of the medical substance administered
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^17^01131^Substance Manufacturer Name| |RXD^20^01131^Substance Manufacturer Name| |RXG^21^01131^Substance Manufacturer Name|
A code identifying the potential of being able to substitute another pharmaceutical.
|RXA^1^00342^Give Sub-ID Counter| |RXG^1^00342^Give Sub-ID Counter|
Special instructions from the pharmacy or treatment supplier to the provider administering the order.
Rationale: makes this specific to a particular V2.3 field
|RXD^15^00330^Pharmacy/Treatment Supplier's Special Dispensing I| |RXE^21^00330^Pharmacy/Treatment Supplier's Special Dispensing I|
The daily dose amount.
Rationale: alignment with V2.3 language
|RXD^12^00329^Total Daily Dose| |RXE^19^00329^Total Daily Dose|
Rationale: link medication dispensed to service catalog
OpenIssue:
Rationale: specify location for individual dispenses
OpenIssue:
Class steward is Orders/Observation
A type of service event in which a pharmacy or treatment service is performed.
An identifier assigned to the pharmacy treatment service event.
|RXD^7^00325^Prescription Number| |RXE^15^00325^Prescription Number|
The number of refills remaining.
Rationale: V2.3 field is NM datatype. there is no unit of measure to specify.
|RXD^8^00326^Number of Refills Remaining| |RXE^16^00326^Number of Refills Remaining|
Class steward is Orders/Observation
The issuing of a pharmacy or treatment give notice.
Free form text.
|RXA^2^00344^Administration Sub-ID Counter| |RXG^13^00343^Pharmacy/Treatment Supplier Special Administration|
A count of the number of administrations of the drug.
Rationale: V2.3 field is NM datatype. there is no unit of measure to specify.
|RXA^1^00342^Give Sub-ID Counter| |RXG^1^00342^Give Sub-ID Counter|
The time unit used to calculate the rate at which the pharmaceutical is to be administered.
Rationale: this is a pure unit of measure, not an amount with an associated unit. V2.3 field is coded.
|RXE^22^00331^Give Per (Time Unit)| |RXG^14^00331^Give Per (Time Unit)|
Specification for one component of the medication or treatment in the pharmacy give notice.
Rationale:
OpenIssue:
|RXC^5^01124^Component Strength|
Specification for one route of administration for the medication or treatment in the pharmacy give notice. Specification includes route, site, administration device and administration method.
Rationale:
OpenIssue:
|RXR^3^00311^Administration Device|
A means of specifying when the service described by the give notice is to be performed and how frequently. It is a complex multicomponent field that can have repeats. This field contains the quantity/timing specification that refers to either a single scheduled give instruction only or to multiple give instructions. In the former case, RXG-1-give sub-ID counter is a positive integer greater than or equal to one (1). In the latter case, RXG-1-give sub-ID counter is zero (0). The quantity will always be 1. The pharmacy or treatment department has the "authority" (and/or necessity) to schedule dispense/give events. Hence, the pharmacy or treatment department has the responsibility to encode this scheduling information for the pharmacy service order item and pharmacy service give notice. The quantity/timing for the patient service order does not change: it always specifies the requested give/dispense schedule of the original order
|OBR^27^00221^Quantity/Timing| |ORC^7^00221^Quantity/Timing| |RXE^1^00221^Quantity/Timing| |RXG^3^00221^Quantity/Timing|
The amount (number) of substance to be administered.
|RXE^23^00332^Give Rate Amount| |RXG^15^00332^Give Rate Amount|
This field contains the identifier of the condition or problem for which the drug/treatment was prescribed.
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^19^01123^Indication| |RXD^21^01123^Indication| |RXG^22^01123^Indication| |RXO^20^01123^Indication|
The maximum ordered amount.
|RXE^4^00319^Give Amount - Maximum| |RXG^6^00319^Give Amount - Maximum|
The minimum order amount.
|RXE^3^00318^Give Amount - Minimum| |RXG^5^00318^Give Amount - Minimum|
An indication that the pharmacist filling the order needs to pay special attention to the order notes.
|RXD^14^00307^Needs Human Review| |RXE^20^00307^Needs Human Review| |RXG^12^00307^Needs Human Review| |RXO^16^00307^Needs Human Review|
the expiration date of the medical substance
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^16^01130^Substance Expiration Date| |RXD^19^01130^Substance Expiration Date| |RXG^20^01130^Substance Expiration Date|
This field contains the lot number of the medical substance.
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^15^01129^Substance Lot Number| |RXD^18^01129^Substance Lot Number| |RXG^19^01129^Substance Lot Number|
This field contains the manufacturer of the medical substance administered
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^17^01131^Substance Manufacturer Name| |RXD^20^01131^Substance Manufacturer Name| |RXG^21^01131^Substance Manufacturer Name|
A code indicating the status of a drug substitution in a pharmacy service give.
|RXD^11^00322^Substitution Status| |RXE^9^00322^Substitution Status| |RXG^10^00322^Substitution Status|
pharmacy/treatment supplier-generated special instructions to the provider administering the order.
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXG^13^00343^Pharmacy/Treatment Supplier Special Administration|
Rationale: specify dispense location for individual give notices
OpenIssue:
Class steward is Orders/Observation
An authoritative direction or instruction concerning the dispensement of medication to a patient.
The dosage to be administered.
The earliest date the medication can be dispensed.
This field contains the identifier of the condition or problem for which the drug/treatment was prescribed.
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^19^01123^Indication| |RXD^21^01123^Indication| |RXG^22^01123^Indication| |RXO^20^01123^Indication|
An indication that a pharmacy order for an out of formulary item is authorized.
Free form instructional text for the pharmacy order.
Rationale: makes this specific to a particular V2.3 field
|RXE^7^00298^Provider's Administration Instructions| |RXO^6^00297^Provider's Pharmacy Instructions| |RXO^7^00298^Provider's Administration Instructions|
A reason code for rejection of a pharmacy order.
the rate at which to administer treatment, as specified by the ordering physician
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXO^22^01219^Requested Give Rate Units|
Specifies the strength of the medication as requested on the order, when it is not included in the Universal Service Identifier
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXO^19^01122^Requested Give Strength Units|
An indicator that a substitution medication is allowed.
|RXO^9^00300^Allow Substitutions|
the pharmacy or treatment supplier's provider-generated special instructions to the provider dispensing/administering the order
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXD^15^00330^Pharmacy/Treatment Supplier's Special Dispensing I| |RXE^21^00330^Pharmacy/Treatment Supplier's Special Dispensing I|
An indication that verification is required.
Class steward is Orders/Observation
The collection of characteristics for a pharmacy treatment order that can be revised during the course of processing the order. Pharmacy encoding is an example of a process that may revise order characteristics. This "revisions" class allows tracking of changes made to the order, and representation of the order at any stage in its processing.
Rationale: Class name changed to better represent usage. There is no sense in which the contents of this class represent an "item" of the pharmacy order.
OpenIssue: Note that this is used to surface the information carred in the Pharmacy Encoded segment of v2.3, and this name ‘revision’ may need to be changed to be more appropriate.
the method by which treatment is dispensed, eg. Traditional, unit-dose, floor stock, automatic dispensing
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXD^24^01222^Dispense Package Method| |RXE^30^01222^Dispense Package Method|
This field contains the size of package to be dispensed
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXD^22^01220^Dispense Package Size| |RXE^28^01220^Dispense Package Size|
condition or problem for which the drug/treatment was prescribed
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXE^27^01128^Give Indication|
The number of gives per unit of time.
|RXE^22^00331^Give Per (Time Unit)| |RXG^14^00331^Give Per (Time Unit)| |RXO^17^00308^Requested Give Per (Time Unit)|
The rate of give for the medication.
|RXE^23^00332^Give Rate Amount| |RXG^15^00332^Give Rate Amount|
A indication that the pharmacy order required human review.
|RXD^14^00307^Needs Human Review| |RXE^20^00307^Needs Human Review| |RXG^12^00307^Needs Human Review| |RXO^16^00307^Needs Human Review|
The maximum amount of medication to be administered.
|RXE^4^00319^Give Amount - Maximum| |RXG^6^00319^Give Amount - Maximum| |RXO^3^00294^Requested Give Amount - Maximum|
The minimum amount of medication to be administered.
|RXE^3^00318^Give Amount - Minimum| |RXG^5^00318^Give Amount - Minimum| |RXO^2^00293^Requested Give Amount - Minimum|
An indication that a pharmacy order for an out of formulary item is authorized.
Specification for one component of the ordered medication or treatment
Rationale:
OpenIssue:
|RXC^4^00316^Component Units|
Specification for one route of administration for the ordered medication or treatment. Specification includes route, site, administration device and administration method.
Rationale:
OpenIssue:
|RXR^2^00310^Site|
A means of specifying when the service described by the give notice is to be performed and how frequently. It is a complex multicomponent field that can have repeats. The pharmacy or treatment department has the "authority" (and/or necessity) to schedule dispense/give events. Hence, the pharmacy or treatment department has the responsibility to encode this scheduling information for the pharmacy service order item and pharmacy service give notice. The quantity/timing for the patient service order does not change: it always specifies the requested give/dispense schedule of the original order
Rationale:
OpenIssue:
The method to be used to administer the medication.
|RXR^4^00312^Administration Method|
The information about how many services to perform at one service time and how often the service times are repeated, and to fix duration of the request.
|OBR^27^00221^Quantity/Timing| |ORC^7^00221^Quantity/Timing| |RXE^1^00221^Quantity/Timing| |RXG^3^00221^Quantity/Timing|
the ordering provider's instructions to the patient or the provider administering the drug or treatment
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXE^7^00298^Provider's Administration Instructions| |RXO^7^00298^Provider's Administration Instructions|
The number of refills doses dispensed.
|RXE^17^00327^Number of Refills/Doses Dispensed|
The number of refills remaining.
|RXD^8^00326^Number of Refills Remaining| |RXE^16^00326^Number of Refills Remaining|
The number of refills remaining.
|RXD^8^00326^Number of Refills Remaining| |RXE^16^00326^Number of Refills Remaining|
Substitution status of the pharmacy order.
|RXD^11^00322^Substitution Status| |RXE^9^00322^Substitution Status| |RXG^10^00322^Substitution Status|
the pharmacy or treatment supplier's provider-generated special instructions to the provider dispensing/administering the order
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXD^15^00330^Pharmacy/Treatment Supplier's Special Dispensing I| |RXE^21^00330^Pharmacy/Treatment Supplier's Special Dispensing I|
the total daily dose for this particular pharmaceutical as expressed in terms of actual dispense units.
Rationale: all RXE fields should appear in RIM08 Pharmacy_service_order_item
OpenIssue:
|RXD^12^00329^Total Daily Dose| |RXE^19^00329^Total Daily Dose|
Total daily dosage code.
|RXD^12^00329^Total Daily Dose| |RXE^19^00329^Total Daily Dose|
Rationale:
OpenIssue: Orders committee asked for this to be connected to the class "Patient_service_order_revision", but there is no such class in the model.
Rationale: link medication on pharmacy_service_order_item to service catalog
OpenIssue: