Copyright 1999 by Health Level Seven, Inc.
Link to Subjects
Link to Stewardship and Class interests and DIMs
This data model was HTML encoded by software prepared for the HL7. Comments on presentation links or any bugs encountered may be addressed to:
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Organization: Health Level Seven
Version: V 0-88 19901111
Developed by: Modeling and Methodology
A collection of master tables related to clinical pathways.
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Certification_second_opinion |
Guarantor_contract |
Insurance_certification |
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Champus_coverage Healthcare_benefit_coverage |
Healthcare_benefit_product Healthcare_benefit_service |
Medicaid_coverage Medicare_coverage |
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Master_calculated_observation Master_categorical_observation |
Master_continuous_observation Master_observation_service |
Master_specimen_requirement |
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Bad_debt_collection_agency Identifier_issuing_authority |
Insurer |
Organization |
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Bad_debt_billing_account Billing_information_item |
Financial_transaction |
Patient_billing_account |
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Condition_node |
Goal |
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Location_encounter_role |
Master_patient_service_location |
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Dietary_intent_or_order Observation_intent_or_order Referral |
Service_intent_or_order Service_intent_or_order_relationship |
Treatment_intent_or_order Treatment_intent_or_order_revision |
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Contact_person Employee Notary_public |
Person Person_alternate_name Person_employment |
Stakeholder_affiliate Transcriptionist |
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Treatment_service_administration Treatment_service_dispense |
Treatment_service_event |
Treatment_service_give |
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Master_numeric_range Master_service |
Master_service_relationship |
Master_treatment_service |
This draft HL7 Reference Information Model (RIM) is the result of the fourth HL7 RIM harmonization cycle. RIM change proposals from several HL7 Technical Committees were reviewed and acted upon during a RIM Harmonization Meeting held November 18-19, 1998 in Dallas, TX. Technical Corrections were applied the first week in January, 1999.
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 September 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 Orders/Observation
A stakeholder that is the source of information concerning a reported patient accident.
Rationale: Limit the scope of class to the information for which stakeholder is source.
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begin_dttm duration_tm |
end_dttm participation_type_cd |
Class steward is Orders/Observation
A role class that captures the multiple roles various entities play e.g., orderer, attending, witness, transcriber, etc., in delivering a service to a target of service.
Rationale: Since multiple entities participate in the delivery of services to particular targets of service, a role class is needed to capture the multiple roles these participants play in delivering a service to a target of service.
OpenIssue: There is as need to re-examine the manner in which attending physicians is representing because this will cause two different ways of identifying it.
The effective and time of the active participation.
Rationale: Manage active participations.
The elapsed time during which the active participation is in effect.
Rationale: Manage active participations.
The termination date and time for the active participation.
Rationale: Manage active participations.
The nature or purpose of the participant's participation. Examples: order healthcare practitioner, service event provider, advance directive witness, notarizer.
Rationale: Manage active participations.
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baby_detained_ind birth_certificate_id birth_method_cd birth_recorded_county_cd |
birth_recorded_dt newborn_days_qty stillborn_ind |
Class steward is Patient Administration
Interested committees Orders/Observation
The act or process of bearing or bringing forth offspring. The information contained in this pertains to the newborn (not the mother.)
Rationale: Better reflection of the administrative nature of this class.
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.
A code depicting the method of birth (e.g., caesarean, vaginal, forceps, . . .).
The county in which the person's birth record is recorded.
The date the birth event was recorded.
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.
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accident_death_ind accident_desc accident_dttm accident_location_desc |
accident_state_cd accident_type_cd assessment_dttm job_related_accident_ind |
Class steward is Patient Administration
Interested committees Orders/Observation
An undesirable or unfortunate happening that occurs unintentionally and usually results in harm, injury, damage, or loss.
Rationale: Better reflection of the administrative nature of this class.
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|
The date and time the accident was identified.
Rationale: Move inherited attribute to specialization in order to allow removal of generalization (patient)clinical_item) with single specialization.
|AL1^6^00208^Identification Date|
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|
Rationale: Allows removal of generalization (patient_clinical_item) with single specialization
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death_certificate_id death_certificate_recorded_dt death_classification_cd death_dttm death_location_nm |
death_notification_source_nm death_verification_cd death_verification_dt death_verification_nm |
Class steward is Patient Administration
Interested committees Orders/Observation
The act of dying; the end of life; the total and permanent cessation of all the vital functions of a patient.
Rationale: Better reflection of the administrative nature of this class.
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.
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assessment_dttm competence_ind directive_cd disclosure_level_cd |
employment_related_ind life_quality_desc mortuary_preference_nm notarization_dt |
Class steward is Information Management (Medical Records)
Interested committees Patient Administration
An authoritative instruction or direction of a patient regarding their healthcare or the disposition of their remains.
The date and time the advance directive was identified.
Rationale: To replace attribute previously inherited from Patient_clinical_item.
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.
An indication that the advance directive is employment related.
To replace attribute previously inherited from Patient_clinical_item.
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.
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allergen_id allergy_cd allergy_reaction_cd allergy_reaction_description_txt |
allergy_severity_cd allergy_type_cd assessment_dttm employment_related_ind |
Class steward is Orders/Observation
Interested committees Patient Administration
An abnormal reaction of a patient to an allergen.
Rationale: Generalize usage
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|
The date and time the allergy was identifier.
Rationale: To replace attribute inherited from Patient_clinical_item.
n indication that the allergy is employment related.
Rationale: To replace attribute previously inherited from Patient_clinical_item.
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Interested committees Patient Administration
A planned patient encounter set for a specific time and place.
A code depicting the disposition of the appointment (e.g., pending, canceled, rescheduled, . . .).
Amount of time allotted for the appointment. In cases of repeating appointments, this field describes the duration of one instance of the appointment.
Rationale: Currently in 2.3
OpenIssue:
|ARQ^9^00868^Appointment Duration| |SCH^9^00868^Appointment Duration|
The reason that the appointment is to take place.
Rationale: Currently in 2.3
OpenIssue:
|ARQ^7^00866^Appointment Reason| |SCH^7^00866^Appointment Reason|
A code depicting the reason the appointment is being requested.
The scheduled appointment’s timing and quantity as scheduled by the filler application.
Rationale: Currently in 2.3
OpenIssue:
|SCH^11^00884^Appointment Timing Quantity|
Code for the type of appointment
Rationale: Currently in 2.3
OpenIssue:
|ARQ^8^00867^Appointment Type| |SCH^8^00867^Appointment Type|
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.
Code for the reason that the notification event was triggered. It may describe the cancel reason, the delete reason, the discontinue reason, the add reason, the block reason or others.
Rationale: Currently in 2.3
OpenIssue:
|SCH^6^00883^Event Reason|
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.
Uniquely identifies an individual occurrence (a child) of a parent repeating schedule appointment.
Rationale: Currently in 2.3
OpenIssue: might turn into a recursive relationship on the class
|ARQ^3^00862^Occurrence Number| |SCH^3^00862^Occurrence Number|
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.
Code describing the status of the appointment with respect to the filler application.
Rationale: Currently in 2.3
OpenIssue:
|AIG^14^00889^Filler Status Code| |AIL^12^00889^Filler Status Code| |AIP^12^00889^Filler Status Code| |AIS^10^00889^Filler Status Code| |SCH^25^00889^Filler Status Code|
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.
Links a schedule to its contents.
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role_cd |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
The person responsible for requesting, entering, or filling the scheduling of a requested appointment
Rationale: Currently in 2.3
OpenIssue: This looks like a participation role. Reexamine.
Role that a contact person plays relative to an appointment request
Rationale: Currently in 2.3 as itemized person information for each role
OpenIssue:
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
A request for the booking of an appointment.
Rationale: Separates an appointment from a request for an appointment.
OpenIssue:
The reason that the appointment is to take place. Examples are: ROUTINE, WALKIN, CHECKUP, FOLLOWUP, EMERGENCY.
Rationale: Currently in 2.3
OpenIssue: It appears that this attribute has the potential to be used for two types of codes that should be mutually exclusive (local site specific code, and the other is a service code) combining an administrative reason with the thing to be performed
|ARQ^7^00866^Appointment Reason| |SCH^7^00866^Appointment Reason|
The type of appointment request. Examples are: NORMAL, TENTATIVE, COMPLETE.
Rationale: Currently in 2.3
OpenIssue:
|ARQ^8^00867^Appointment Type| |SCH^8^00867^Appointment Type|
Parameters and preferences regarding the selection of an appropriate resource for an appointment. The first component of this field is a code identifying the parameter or preference and the second component is the actual data value for that parameter.
Rationale: Currently in 2.3
OpenIssue: Proposed data type that accommodates parameter, value pairs where the pairs are drawn from a user defined table.
|APR^2^00909^Resource Selection Criteria|
Unique identifier for an appointment request.
Rationale: Separates appointment from its request.
OpenIssue:
|ARQ^1^00860^Placer Appointment ID| |SCH^1^00860^Placer Appointment ID|
Parameters and preferences regarding the selection of an appropriate location for the appointment.
Rationale: Currently in 2.3
OpenIssue: Proposed data type that accommodates parameter, value pairs where the pairs are drawn from a user defined table.
|APR^3^00910^Location Selection Criteria|
Uniquely identifies an individual occurrence (a child) of a parent repeating schedule appointment.
Rationale: Currently in 2.3
OpenIssue: Probably do not need this class, could make a recursive relationship on Appointment_request
|ARQ^3^00862^Occurrence Number| |SCH^3^00862^Occurrence Number|
The urgency of the request.
Rationale: Currently in 2.3
OpenIssue:
|ARQ^12^00871^Priority|
How long the appointment repetitions should continue, once they have begun.
Rationale: Currently in 2.3
OpenIssue:
|ARQ^14^00873^Repeating Interval Duration|
The interval between repeating appointments.
Rationale: Currently in 2.3
OpenIssue: May require a new data type or attribute group. Talk to CQ about the need for a repeating interval datatype
|ARQ^13^00872^Repeating Interval|
A code describing the cancel reason, the delete reason, the discontinue reason, the add reason, or any other code describing the reason for a specific request event.
Rationale: Currently in 2.3
OpenIssue:
|ARQ^6^00865^Request Event Reason|
The amount of time being requested for the appointment.
Rationale: Currently in 2.3
OpenIssue:
|ARQ^9^00868^Appointment Duration| |SCH^9^00868^Appointment Duration|
The date and time that the appointment is requested to begin in the form of a date/time range.
Rationale: Currently in 2.3
OpenIssue: Proposed new attribute type not currently supported. Needs to be proposed to CQ for the DT/AT work.
|ARQ^11^00870^Requested Start Date/Time Range|
Parameters and preferences regarding the selection of an appropriate time slot for an appointment.
Rationale: Currently in 2.3
OpenIssue: Proposed data type that accommodates parameter, value pairs where the pairs are drawn from a user defined table. Needs new attribute type mapping to DT:PV
|APR^1^00908^Time Selection Criteria|
Class steward is Orders/Observation
A subclass of Service_event and a superclass that captures the data related to a kind of service that represents abstraction and interpretation of data from a data source and includes observations, metaobservations, assignment of an observation or metaobservation to a problem list of allergy list or goal e.g. lab results, question results, physical exam results, impressions problem list entry, allergy list entry, goal assignment, etc. This class is orthogonal to Care_event
Rational: Since multiple kinds of assessments are delivered as a healthcare service, a class is needed to record the nature of those assessments and the resulting values(s) associated with those assessments. An assessment is a kind of service that describes the collection and interpretation of data from a data source and the nature of that data. In this class, it also describes the value(s) associated with the action of data collection and interpretation.
OpenIssue: Need a better name.
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authentication_dt |
type_cd |
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:
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bad_debt_recovery_amt bad_debt_transfer_amt |
transfer_to_bad_debt_dt transfer_to_bad_debt_reason_cd |
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.
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condition_cd occurrence_cd occurrence_dt occurrence_span_cd occurrence_span_from_dt |
occurrence_span_thru_dt quantity_amt quantity_type_cd value_amt value_cd |
Class steward is Patient Administration
Billing account information particular to the national uniform billing form.
A code depicting a condition.
EXTREF: This information is reported on UB92 FL 24-30.
|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.
EXTREF: This information is reported on UB92 FL 32-35.
|UB1^16^00545^Occurrence (28-32)| |UB2^7^00559^Occurrence Code & Date (32-35)|
The date of the event depicted in occurrence code.
EXTREF: This information is reported on UB92-35.
|UB2^7^00559^Occurrence Code & Date (32-35)|
A code depicting an event which occurs over a span of time.
EXTREF: This information is reported on UB92 FL 36.
|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.
EXTREF: This inormation is reported on UB92 FL 36.
|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.
EXTREF: This information is reported on UB92 FL 36.
|UB1^15^00544^PSRO/UR Approved Stay-To (89)| |UB1^19^00548^Occur Span End Date (33) | |UB2^8^00560^Occurrence Span Code/Dates (36)|
A quantitative value on a bill. The value is qualified by quantity type code.
EXTREF: The quantity of covered days, non-covered days, and co-insurance days are reported on UB92 FL 7, 8, and 9.
|UB1^3^00532^Blood Furnished-Pints Of (40)| |UB1^4^00533^Blood Replaced-Pints (41)| |UB1^5^00534^Blood Not Replaced-Pints(42)| |UB1^6^00535^Co-Insurance Days (25)| |UB1^8^00537^Covered Days (23) | |UB1^9^00538^Non Covered Days (24) | |UB1^11^00540^Number Of Grace Days (90) | |UB2^2^00554^Co-Insurance Days (9)| |UB2^4^00556^Covered Days (7)| |UB2^5^00557^Non-Covered Days (8)| |UB2^17^00815^Special Visit Count|
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.
EXTREF: This information is reported on UB92 FL 39-41.
|UB1^10^00539^Value Amount & Code (46-49)| |UB2^6^00558^Value Amount & Code|
A code qualifying the billing information value amount.
EXTREF: This information is reported on UB92 FL 39-41.
|UB1^10^00539^Value Amount & Code (46-49)| |UB2^6^00558^Value Amount & Code|
Class steward is Orders/Observation
A subclass of Service_event and a superclass that captures the data related to a kind of service that produces a change in the target of service and includes medication administration, surgeries, teaching, dressing changes, therapeutic listening, etc. This class is orthogonal to Assessment_event.
Rationale: Since some healthcare services produce changes in the target of service, these actions need to be captured and statused with their own set of attributes.
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effective_dt |
status_cd |
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.
|IN3^23^00524^Second Opinion Status | |IN3^24^00525^Second Opinion Documentation Received|
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handicapped_program_cd non_avail_cert_on_file_ind |
retirement_dt station_id |
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 Information Management (Medical Records)
Interested committees Orders/Observation
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.
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|
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:
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 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.
OpenIssue: Consideration should be given to the identification that the Gen-Spec (clinical_observation is a specialization of Assessment) may be flawed and that it may be replaced with a simple association.
An indication that the observation results are abnormal.
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|
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|
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 observation's 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|
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|
The 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|
Rationale: Add Procedure as possible source of specimen.
Rationale: Replaces association Collected_specimen_sample is_used_during Service_event.
|
actual_resolution_dttm employment_related_ind estimated_resolution_dttm life_cycle_status_dttm lifecycle_status_cd |
management_discipline_cd onset_dttm onset_time_txt ranking_amt |
Class steward is Patient Care
Interested committees Orders/Observation
An action which is an Assessment that defines the status of a condition thread at a given point in time. Condition thread is defined by service event relationships between condition_nodes.
OpenIssue: Definition needs further work. Use of the word thread needs to be re-examines. The committee should consider defining the thread as a separate recursion. Get an example.
The date/time that the condition was actually resolved.
An indication that the diagnosis is employment related.
Rationale: To replace attribute previously inherited by Diagnosis from Patient_clinical_item
OpenIssue: Should this be handled as an explicit diagnosis in Health_issue or should it be deleted completely, or does this require longitudinal linkage through Condition_node?
The estimated date/time for resolving the stated condition.
OpenIssue: Is this a kind of a goal or not?
This field indicates the effective date/time of the current condition life cycle status.
This field indicates the effective date/time of the current condition life cycle status.
OpenIssue: Accept attribute description of life_cycle_status_cd. Redefine life_cycle_start_dttm.
The category of caregiver with interest in a specific condition thread (e.g., nursing, medicine, respiratory therapy, dietary, etc.). This is a repeating field to allow identification of all disciplines who may have interest in this condition.
Rationale: 2.3 definition was wrong.
OpenIssue: Has to be multiple, and how can we indicate when a particular category initiates or withdraws their indicated interest.
This field contains the date/time when the condition actually began as determined by the caregiver.
OpenIssue: This and the Condition_code.onset_time_text attribute need to be considered in a new either/or data type (precise or imprecise) for a dual kind of time.
This field allows for a textual and imprecise representation of the time when the condition began.
OpenIssue: This and Condition_node.onset_dttm attribute need to be considered in a new either/or data type (precise or imprecise) for a dual kind of time
This field is used to rank this condition when placing multiple conditions on an ordered list.
OpenIssue: Issue of ranking and priority needs remodeling-both need to be considered as single chang; should this be numeric attribute type? People are uncomfortable with the issue of ranking and priority. Need to consider this attribute with problem_list_priority.
Class steward is Information Management (Medical Records)
A subclass of Service_event that records the collection of consent signatures.
Rationale: Healthcare requires consents to be collected from various parties prior to some services. m This class allows recording of that action.
|
contact_reason_cd |
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| |IN2^51^00791^Employer Contact Reason | |IN2^54^00794^Insured’s Contact Person 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.
Rationale: DG1^8 was retained in v2.3 for backward compatibility only.
<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>
|
diet_type_cd dietary_instruction_desc dietary_tray_type_cd |
service_period_cd service_type_cd |
Class steward is Orders/Observation
An authoritative direction or instruction concerning the system or course of diet for a patient.
Rationale: Conformance to new name for generalization
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|
|
effective_dt return_to_work_auth_dt |
termination_dt unable_to_work_effective_dt |
Class steward is Patient Administration
Information about non-permanent disabilities. (Permanent disabilities are represented by Person.disability_cd.)
Rationale: DB1 segment
OpenIssue: How should this be associated with the Patient_encounter class? See DB1-4
The date that this administrative disability became effective.
Rationale: DB1-5
OpenIssue:
|DB1^5^01287^Disability Start Date|
The date the person was authorized to return to work.
Rationale: DB1-7
OpenIssue:
|DB1^7^01289^Disability Return to Work Date|
The date that this disability ended.
Rationale: DB1-6
OpenIssue:
|DB1^6^01288^Disability End Date|
The date the person was unable to work due to this disability.
Rationale: DB1-8
OpenIssue:
|DB1^8^01290^Disability Unable to Work Date|
Rationale: 2.3 abstract message definition
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:
|
id slot_size_increment_qty |
type_cd |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
A tangible material item used to perform a Healthcare Service.
Rationale: Currently in 2.3
OpenIssue: Who is the logical steward - not really a scheduling class.
A unique identifier for a specific piece of equipment.
Rationale: Currently in 2.3
OpenIssue:
|AIG^3^00897^Resource ID|
Duration for a single schedulable unit in a schedule for a resource.
Rationale: Provides visibility into scheduling details.
OpenIssue: Does this match any V2.3 field?
Identifies the role of the resource requested/scheduled for an appointment
Rationale: Creates a separate class for types of equipment
OpenIssue:
|AIG^3^00897^Resource ID|
Rationale:
OpenIssue: It would be nice to have a description and rationale for this connection.
|
id |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
A pool of like-type equipment available for scheduling purposes.
Rationale: Currently in 2.3
OpenIssue:
Unique identifier for the group
Rationale: Currently in 2.3
OpenIssue:
|AIG^5^00899^Resource Group| |AIP^5^00899^Resource Group|
|
quantity_amt |
type_cd |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Request information about equipment that is controlled by a schedule
Rationale: Specializes the request by type of resource
OpenIssue:
The quantity of the specified resource or resource type.
Rationale: Currently in 2.3
OpenIssue: We would like better )more explanatory) names for attributes that are meaningful by themselves without the class prefix. Needs to be addressed by MnM in the style guide more clearly.
|AIG^6^00900^Resource Quantity|
Identifies the role of the resource requested/scheduled for an appointment
Rationale: Creates a separate class for types of equipment
OpenIssue:
|AIG^3^00897^Resource ID|
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
An allocation of time defined when a specific piece of medical equipment is available for use for a healthcare service.
Rationale: future
OpenIssue:
Rationale:
OpenIssue: It would be nice to have a description and rationale for this connection.
Class steward is Patient Administration
An employed person.
|
effective_dt |
termination_dt |
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.
|
approval_ind assigned_dttm confidential_ind cost_outlier_amt desc |
grouper_review_cd grouper_version_id outlier_days_qty outlier_reimbursement_amt outlier_type_cd |
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 or has not been approved by a reviewing entity.
Rationale: DG1^9 was retained in v2.3 for backward compatibility only. This field isan indicator and the definition should clearly reflect that.
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.
Rationale: DG1^13 was retained for backward compatibility only.
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.
Rationale: DG1^10 was retained for v2.3 for backward compatibility only.
The version and type of the grouper used to derive the DRG.
Rationale: DG1^14 was retained for v2.3 for backware compatibility only and the DRG reference should be used.
|URS^4^00055^R/U What User Qualifier|
The number of days beyond the standard day count for the assigned DRG.
Rationale: DG1^12 was retained for v2.3 for backward compatibility only
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.
Rationale: This is the v2.3 reference
|DG1^11^00385^Outlier Type| |DRG^5^00385^Outlier Type|
|
participation_type_cd |
Class steward is Patient Administration
Interested committees Orders/Observation
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 (e.g. attending physician, admitting physician, consulting physician, referring physician).
|
desc episode_type_cd id |
list_closed_ind outcome_txt recurring_service_ind |
Class steward is Patient Care
Interested committees 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.
|
alternate_desc desc extended_amt fee_schedule_cd insurance_amt posting_dt qty |
transaction_batch_id transaction_cd transaction_dt transaction_id transaction_type_cd unit_amt unit_cost_amt |
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|
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
The assignment of a hoped-for observation value or metaobservation value on a particular target of service on a specific date in the future.
Rationale: For Goal is specialization of Assessment- this class captures the hope to meet a specific goal by a specific date. Note that the measurement of the gap between the "real observation" and the hope is itself a metaobservation and is captured under Calculated_observation. Also note that the measurement of the "real observation" is captured as well under Target_observation.
Event code for why the object is included.
Rationale: Conformance with v 2.3
OpenIssue:
|GOL^1^00816^Action Code| |PRB^1^00816^Action Code| |PTH^1^00816^Action Code| |ROL^2^00816^Action Code|
Event date time
Rationale: Conformance with v 2.3
OpenIssue:
|GOL^2^00817^Action Date/Time| |PRB^2^00817^Action Date/Time|
A code used to categorize patient pathway goals.
A code depicting the review status of the patient pathway goal.
The date/time of the most recent review of the patient pathway goal.
Episode of Care
Rationale: Conformance with v 2.3
OpenIssue:
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.
Date goal is expected to be achieved
Rationale: Conformance with v 2.3
OpenIssue:
Standard code or name for the goal.
Rationale: Vocabulary reference
Priority of the goal within the scope of the entire goal list.
Rationale: Conformance with v 2.3
OpenIssue:
|GOL^6^00821^Goal List Priority|
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.
A code indication the review interval for the patient pathway goal.
Text description of who/what the goal target is.
Rationale: Conformance with v 2.3
OpenIssue:
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, . . .).
|
financial_class_cd household_annual_income_amt |
household_size_qty |
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|
|
billing_hold_ind billing_media_cd charge_adjustment_cd contract_duration_cd contract_type_cd |
effective_dt interest_rate_amt periodic_payment_amt priority_ranking_cd termination_dt |
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.
|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|
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.
|
health_chart_id health_chart_type_cd |
status_cd |
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.
|
assessment_dt desc |
level_cd type_cd |
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.
|
billing_priority_amt cd classification_cd confirmation_status_cd diagnosis_cd onset_dttm |
persistence_cd probability_amt probability_txt prognosis_awareness_desc prognosis_desc severity_cd |
Class steward is Patient Care
Interested committees Orders/Observation
An action which asserts the presence of an impression, conclusion, or diagnosis or other derived observation about the patient or the patient's environment.
OpenIssue: It is not clear how to represent Patient signs and symptoms. Are derived observations restricted to Health_issues class?
Sequences Health_issue (usually diagnoses) for billing into an ordered list.
Rationale: Used to differentiate purpose from other ranking attributes
|DG1^15^00389^Diagnosis Priority|
A coded metaobservation (observation about observations) that may be an impression, conclusion, or diagnosis.
|DG1^6^00380^Diagnosis Type| |DG1^17^00766^Diagnosis Classification| |FT1^19^00371^Diagnosis Code| |PR1^15^00772^Associated Diagnosis Code|
Kind of health_issue. May be used to categorize health issues so that they may be managed and viewed independently within different applications (e.g., admission, final post-operative, pre-operative, outpatient, discharge, medical records, billing, etc.).
A code depicting the level of verification for the patient problem (e.g., confirmed, differential, provisional, rule-out, . . .).
OpenIssue: Should this be combined with Health_issue.slassification_cd.
|DG1^6^00380^Diagnosis Type|
A unique identifier designating the diagnosis.
|DG1^3^00377^Diagnosis Code| |FT1^19^00371^Diagnosis Code| |PR1^15^00772^Associated Diagnosis Code|
Actual time that this Health_issue was determined to have begun in the Patient
OpenIssue: Need to review all of the time stamps in the entire Service_event specialization tree (CQ) in order to be certain there is no redundancy and the names, precision, and definitions are correct and clear.
|DG1^5^00379^Diagnosis Date/Time|
Contains the persistence of a health issue (e.g., acute, chronic, etc.).
OpenIssue: change the definition to be clearer and to not use the word persistance in both the definition and the name of the attribute.
Contains a numeric representation of the certainty that the health issue exists for this patient. This field has a valid range of 0 to 1. For example, a healthcare provider may be 75% (.75) sure that the health issues has been correctly identified.
This field contains a qualitative representation of the certainty of a health issue (e.g., HI - high, LO - low, ME - medium, etc.).
OpenIssue: Submit to CQ the need to develop data types to cover concepts that may be specified either as exact numbers or as fuzzy string values. This one is covered by that as well.
A indication of the patient's awareness of the prognosis for the problem.
OpenIssue: Patient Care needs to evaluate whether or not Prognosis is a subclass of Service_event.
This field contains the prognosis relating to the service event (e.g., good, poor, etc.).
OpenIssue: Note that the prognosis may be a separate assessment rather than a separate attribute in Health_issue.
A code depicting the severity of the diagnosis.
Class steward is Patient Administration
A defined level of healthcare insurance coverage.
Rationale: Consistency with other Healthcare_benefit classes.
A code serving as an additional refinement of an insurance plan. (e.g., standard, unified, maternity, . . .).
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN1^31^00456^Type of Agreement Code|
The annual limit amount for the Healthcare coverage benefit.
An indication of the existence of baby coverage under the insurance plan.
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN2^19^00490^Baby Coverage|
A textual description of the benefit.
The name of the benefit product.
The deductible amount for blood.
Rationale: This attribute is more approprriately related to a healthcare coverage benefit.
|IN2^21^00492^Blood Deductible|
An indication as to whether the patient has reached the copay limit.
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN2^67^00807^Copay Limit Flag|
The amount of the daily deductible for this insurance plan.
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN2^30^00501^Daily Deductible|
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.
A code depicting the reason why a service is not covered.
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN2^24^00495^Non-Covered Insurance Code|
The code classifying the amount (e.g. AT-Amount, PC-Percentage, LM-Limit)
Rationale: IN2-29. This attribute is more appropriately related to a healthcare coverage benefit.
OpenIssue:
|IN2^29^00500^Policy Type/Amount|
The benefit limit amount or percentage.
Rationale: IN2-29. This attribute is more appropriately related to a healthcare coverage benefit.
OpenIssue:
|IN2^29^00500^Policy Type/Amount|
The policy category code (e.g., ANC-ancillary, MMD-major medical)
Rationale: IN2-29. This attribute is more appropriately related to a healthcare coverage benefit.
OpenIssue:
|IN2^29^00500^Policy Type/Amount|
The deductible amount specified by the insurance plan.
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN1^37^00462^Policy Deductible|
The maximum number of days that the insurance policy will cover.
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN1^39^00464^Policy Limit - Days|
A code depicting the extent of the coverage for a participating member (e.g., single, family, . . .).
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN2^59^00799^Policy Scope |
A rate for a given room type.
Rationale: This attribute is more appropriately related to a healthcare coverage benefit.
|IN2^28^00499^Room Coverage Type/Amount|
The date the benefit is no longer in effect.
Class steward is Patient Administration
A collection of health benefits
An indication as to whether the insured agreed to assign the insurance benefits to the healthcare provider.
EXTREF: This onformation is reported on UB92 FL 53.
|IN1^20^00445^Assignment of Benefits|
The name of the benefit plan.
|FT1^14^00368^Insurance Plan ID| |IN1^2^00368^Insurance Plan ID|
A code classifying the benefit plan type (e.g., commercial, Medicare, Medicaid, . . .).
|DRG^8^00770^DRG Payor| |IN1^15^00440^Plan Type|
A description of the healtcare benefit. For example, Healthpol-Plus is a health insurance offering of xyz company that offers additional vison and dental benefits over the standard Healthpol product.
Rationale: Clarify attribute name and definition.
OpenIssue: PAFM needs to continue to work on this definition since it is still to fuzzy. Need additional explicit examples. Committee will continue to work on definition and consult with Information Management.
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 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|
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|
A indication as to whether the healthcare coverage is a group contract.
An identifier for the healthcare coverage benefit plan.
Rationale: Duplicate of Healthcare_benefit_plan.benefit_plan_ID
OpenIssue: For CQ to resolve: we must have a data type for this that covers the instance identifier, the identifier type, and the assigning authority ID. This is a repeatable attribute.
|IN1^35^00460^Company Plan Code| |IN1^36^00461^Policy Number| |IN1^46^00471^Prior Insurance Plan ID|
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 indicating how the policy information was obtained.
|IN2^60^00800^Policy Source | |SCH^22^00800^Policy Source |
A code describing what information, if any, a provider can release about a patient.
EXTREF: This information is reported on UB92 FL 52.
|IN1^27^00452^Release Information Code|
A code depicting the status of the healthcare coverage.
|IN2^16^00487^Champus Status|
The last date of service that the insurance will cover or be responsible for.
|IN1^13^00438^Plan Expiration Date|
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 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
|
board_certification_type_cd board_certified_ind certification_dt effective_dt |
license_id recertification_dt specialty_cd termination_dt |
Class steward is Patient Administration
Interested committees Orders/Observation
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.
Rationale: A person's PCP can be either a practitioner or a provider organization.
|
effective_dt |
termination_dt |
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.
|
desc fellowship_field_cd graduate_school_nm graduation_dt position_cd |
practitioner_type_cd primary_care_ind residency_field_cd slot_size_increment_qty |
Class steward is Patient Administration
Interested committees Orders/Observation
A person responsible for the provision of healthcare services to an individual, or involved in the provision of healthcare related services. This class is not a healthcare_provider_organization. For example, a physician, midwife, nurse practitioner.
Rationale: Clarify definition.
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.
Duration for a single schedulable unit in a schedule for a resource.
Rationale: Provides visibility into scheduling details.
OpenIssue: Does this match any V2.3 field?
|
id |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
A pool of like-type providers available for scheduling purposes.
Rationale: Currently in 2.3
OpenIssue: v2.3 seems to allow different resource types to belong to the same group Is this information contained in the Master Files?
Unique identifier for the group
Rationale: Currently in 2.3
OpenIssue:
|AIG^5^00899^Resource Group| |AIP^5^00899^Resource Group|
|
practitioner_type_cd |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Interested committees Orders/Observation
Request information about specific personnel that are controlled by a schedule.
Rationale: Specializes the request by type of resource
OpenIssue:
A code indicating the type of healthcare professional (e.g., medical doctor, nurse, pharmacist, laboratory worker, . . .).
Rationale: Creates a separate class for types of providers.
OpenIssue:
|AIP^4^00907^Resource Role|
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
An allocation of time defined when a provider is available to perform a healthcare service.
Rationale: future
OpenIssue:
|
actual_days_qty |
estimated_days_qty |
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.
|IN3^6^00507^Certification Date/Time| |IN3^9^00510^Certification Begin Date|
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 a report of eligibility (ROE) was received.
Rationale: IN1-26
OpenIssue: should it be placed in Preauthorization.authorized_period_begin_dt instead? If so then Healthcare_benefit_plan.report_of_eligibility_ind should be moved to that class as well.
|IN1^26^00451^Rpt of Eligibility Date|
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 Eligibility Flag|
The date the certification ends.
|IN3^10^00511^Certification End Date|
|
participation_type_cd |
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, . . .).
|
effective_dt |
termination_dt |
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.
|
accommodation_cd effective_dttm location_role_cd status_cd |
termination_dttm transfer_reason_cd transfer_reason_desc usage_approved_ind |
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 (e.g., assigned, prior, temporary,pending...)
Rationale: Clarify the use of the location role code.
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 location has been or has not been approved.
Rationale: This field is an indicator and the definition should clearly reflect that.
|
derivation_rule_desc |
Class steward is Orders/Observation
A test/observation service for which calculated results are generated.
Rationale: Names were reversed in RIM0084
OpenIssue: Verify that the descriptions are consistent with the new name.
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|
|
abnormal_result_cd allowed_value_type_cd critical_result_cd |
normal_result_cd preferred_coding_system_cd valid_answer_cd |
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 continuous value results are generated.
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|
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|
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|
Rationale: Streamlined modeling of numeric ranges.
|
condition_desc high_gestation_age_amt high_range_amt high_value_amt low_age_amt low_gestation_age_amt |
low_value_amt race_subspecies_txt range_type_cd sex_txt species_txt |
Class steward is Orders/Observation
A defined range of possible results for a continuous valued numeric observation/test.
Rationale: Streamlined modeling of numeric ranges.
Specifies the special conditions for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the upper limit of gestational age for a range of possible results for "numeric" observations/test.
Rationale: Establish this attribute for all ranges Rationale: required by components of V2.3 field
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the upper age limit for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges Establish this attribute for all ranges..
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the upper limit for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges. Establish this attribute for all ranges.
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the lower age limit for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges.
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the lower limit of gestational age for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges.
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the lower limit for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges.
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the race or sub-species for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges.
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the type of numeric range. Types allowed are reference range, critical range, or absolute range.
Rationale: Allow multiple types of ranges in the same class.
Specifies the gender for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges.
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Specifies the species for a range of possible results for "numeric" observations/tests.
Rationale: required by components of V2.3 field. Establish this attribute for all ranges.
OpenIssue:
|OM2^8^00633^Absolute Range for Ordinal & Continuous Obs|
Rationale: Streamlined modeling of numeric ranges.
|
instrument_id permitted_data_type_cd processing_time_qty |
specimen_required_ind typical_turnaround_time_qty |
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|
|
addr closing_dt desc email_address equipment_type_cd id licensed_bed_qty |
nm opening_dt phon service_specialty_cd slot_size_increment_qty status_cd type_cd |
Class steward is Patient Administration
A place where patient services are delivered.
Address of the location.
|LOC^5^00948^Location Address| |RXA^11^00353^Administered-at Location| |RXD^13^01303^Dispense-to Location| |RXE^8^00299^Deliver-to Location| |RXG^11^01303^Dispense-to Location| |RXO^8^00299^Deliver-to 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
For room or bed locations, identifies what types of eqipment are built in, e.g., telemetry equipment.
Rationale: Currently in 2.3 as LOC-8-Location Equipment.
OpenIssue: Note that this is just a placeholder for a 2.3 item and needs more work with internationalization and Inter-Enterprise.
A unique identifier of a patient care location.
|AIL^5^00905^Location Group| |FT1^16^00133^Assigned Patient Location| |LOC^1^01307^Primary Key Value - LOC| |NPU^1^00209^Bed Location| |PV1^1^00131^Set ID - PV1| |PV1^3^00133^Assigned Patient Location| |PV1^6^00136^Prior Patient Location| |PV1^11^00141^Temporary Location| |PV1^39^00169^Servicing Facility| |PV1^42^00172^Pending Location| |PV1^43^00173^Prior Temporary Location| |PV2^1^00181^Prior Pending Location| |RQD^3^00277^Item Code - External| |RXA^11^00353^Administered-at Location| |RXE^8^00299^Deliver-to Location| |RXO^8^00299^Deliver-to Location|
The number of licensed beds at the location.
name of the location.
Opening date of the location.
Phone at the location.
|LOC^6^00949^Location Phone|
The specialty code of the service.
OpenIssue: This attribute may move to a masterfile class later.
|LDP^4^00966^Speciality Type|
Duration for a single schedulable unit in a schedule for a resource.
Rationale: Provides visibility into scheduling details.
OpenIssue: Does this match any V2.3 field?
A code indicating the status of the location.
|NPU^2^00170^Bed Status| |PV1^40^00170^Bed Status|
A code indicating the type of patient care location (e.g., hospital, clinic, hospital ward, room, bed, . . .).
|LOC^3^00945^Location Type-LOC|
Rationale: previously unmatched V2.3 field
OpenIssue:
Rationale: replaces associations: Patient_service_location receives Treatment_service_dispense - Patient_service_location receives_medication_dispense_recorded_on Treatment_service_give - Patient_service_location receives_medication_delivery_specified_on Treatment_intent_or_order_revision.
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 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 Definition for t|
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|
A means of providing default or standard specifications for when the master service is to be performed and how frequently. It is a complex multicomponent field that can have repeats. If a speciment is required for the service, the Priority component contains specimen collection priority rather than processing priority. The extent to which these specifications can be modified in the delivery of the master service to a particular subject of service is regulated by business rules established by each institution.
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, e.g., 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
|OM1^8^00593^Other Names| |OM1^10^00595^Preferred Short Name or Mnemonic for Observation|
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
|OM1^9^00594^Preferred Report Name for the Observation| |OM1^11^00596^Preferred Long 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.
The norm for performing the service across organizational provider and client base.
Rationale:
OpenIssue:
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|
Object which is target of the service.
Rationale: This is not necessarily the patient.
OpenIssue: In order to make this consistent, Orders must move Processing_time and Typical_turnaround_time from the Master_observation_service to this class. Note that it would also be nice to have a better definition.
The primary or preferred unique identifier for the service catalog item.
Rationale: alignment with V2.3 language (in general discussion of this concept)
|AIS^3^00238^Universal Service ID| |OBR^4^00238^Universal Service ID| |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:
|
constraint_txt quantitytiming_qt |
reflex_testing_trigger_rules_desc relationship_type_cd |
Class steward is Orders/Observation
Associates a composite or dependent (target) master service with one of the multiple (source) services which participates in the composition or dependency. Allows specification of constraints for each association.
Rationale: Routine order sets, clinical trials, and pathways require groupings of services such as panels or "batteries" of unlike tests delivered at one time, groupings of the same tests delivered along a timeline, or grouping combination of these concepts.
Note: Linda Quade must go over these details to make certain that the names are all correct, since there are some small errors on the spreadsheet.
Textual description of any arbitrary constraint on the source service when participating in the target service.
Rationale: Detail of a possible relationship between services.
A means of qualifying the relationship between a source and a target Master_service, specifying when the source service is to be performed and how frequently. It is a complex multicomponent field that can have repeats. If a specimen is required for the source service, the Priority component contains specimen collection priority rather than processing priority. The extent to which these specifications can be modified in the delivery of the target master service to a particular subject of service is regulated by business rules established by each institution.
A description of the rules that trigger reflex testing for a service catalog item.
Rationale: Detail of a possible relationship between services
|OM1^35^00620^Rules that Trigger Reflex Testing|
Specifies the basis for the association of the source to the target.
Rationale: Needed for relationship management
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 (e.g., 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|
|
dea_level_cd drug_category_cd formulary_status_cd medication_form_cd |
pharmaceutical_class_cd route_cd therapeutic_class_cd |
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 on pharmacy_service_order_item to service catalog
OpenIssue:
|
aid_category_cd |
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, ...)
|
effective_dt eligibility_cd id lifetime_res_delay_day_qty lifetime_reserve_day_qty |
medicare_coverage_type_cd program_type_cd renal_cd termination_dt |
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.
|
effective_dt notary_county_cd |
notary_state_cd termination_dt |
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.
|
patient_hazard_cd reason_for_study_cd relevant_clinical_information_txt |
reporting_priority_cd specimen_action_cd |
Class steward is Orders/Observation
An authoritative direction or instruction concerning an observation service for a patient.
Rationale: Conformance to new name generalization. Broaden concept of observation at the actual instance level
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|
|
organization_name_type_cd organization_nm |
standard_industry_class_cd |
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.
|GT1^16^00420^Guarantor Employer Name| |GT1^21^00425^Guarantor Organization Name| |IN1^4^00429^Insurance Company Name| |IN1^9^00434^Group Name| |IN1^11^00436^Insured's Group Emp 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| |LOC^4^00947^Organization Name-LOC| |NK1^13^00202^Organization Name-NK1|
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:
|
ambulatory_status_cd birth_order_amt living_arrangement_cd living_dependency_cd |
multiple_birth_ind newborn_baby_ind organ_donor_ind preferred_pharmacy_id |
Class steward is Patient Administration
Interested committees Orders/Observation
A person who may receive, is receiving, or has received Healthcare services.
Identifies the patient's transient state of mobility or factors which impact their state of mobility, e.g., pregnant, ambulates with assistive devices, etc.
Rationale: Enhances the attribute description using existing 2.3 terminology (GT1-34, IN2-32, NK1-18, PV1-15) to provide clarity.
OpenIssue: Should this attribute be moved to person? Verify that permanent vs. transient conditions are handled as separate attributes. Note that the presence of this attribute brings up to question the entire issue of observations and metaobservations made by non0clinicians for non-clinical purposes.
|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 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.
Rationale: Replaces associations: Patient may_be_the_subject_of order - Patient is_subject_of Clinical_observation - Patient has Goal.
Rationale: 2.3 abstract message definition
OpenIssue:
|
admission_dttm admission_reason_cd admission_referral_cd admission_source_cd admission_type_cd |
patient_valuables_desc pre_admit_test_ind readmission_ind valuables_location_desc |
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|
A request for a service to be performed for a specific patient. Rationale: Specializes the request for the patient as a resource. OpenIssue:
|
acuity_level_cd arrival_dttm arrival_type_cd |
medical_service_id mode_cd source_of_arrival_cd |
Class steward is Patient Administration
The arrival of a patient at the location of care for a patient encounter.
A code depiciting the acuity (complexity of patient care, resource intensiveness of the patient care) of a patient's medical condition upon arrival. Values may be derived from formal acuity coding schemes such as RBS.
Rationale: Clarification/correction of definition
OpenIssue: PAFM and PC must work together on defining the concept of severity in the model.
The date and time of the patient's arrival at the location of care.
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 mode of arrival of the patient at the location of care (e.g. car, walk, ambulance).
Rationale: Clarification of definition
A code depicting the source of arrival.
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.
|PV1^20^00150^Financial Class|
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.
An indication as to whether the baby in a delivery patient stay should be billed separately.
Rationale: The attribute description (an indication as to whether the baby in a delivery patient stay should be billed directly) indicates the correct class.
|PD1^9^00761^Separate Bill|
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
|
actual_discharge_disposition_cd discharge_dttm |
discharge_location_id expected_discharge_disp_cd |
Class steward is Patient Administration
The end of a inpatient encounter.
A code depicting the actual disposition of the patient at the time of discharge (e.g., discharged to home, expired, against medical adfice, etc.). This attribute and the expected_discharge_disposition_cd attribute use the same table of values.
Rationale: Clarification of definition
|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 at the time of discharge (e.g., discharged to home, expired, against medical adfice, etc.). This attribute and the actual_discharge_disposition_cd attribute use the same table of values.
Rationale: Clarification of definition
|PV2^27^00728^Expected Discharge Disposition|
Class steward is Patient Administration
Interested committees Orders/Observation
An interaction between a patient and healthcare participant(s) for the purpose of providing patient service(s) or assessing the health status of a patient. For example, outpatient visit to multiple departments, home health support (including physical therapy), inpatient hospital stay, emergency room visit, field visit (e.g., traffic accident), office visit, occupational therapy, telephone call.
OpenIssue: This MUST be discussed with Patient Care in the context of Episode and Service Event definitions. Episode and Encounter definitions needs to be discussed.
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 code indicating the level of publicity allowed for external release about a patient encounter. Examples are no publicity, family only, no publicity constraint.
|PV2^21^00722^Visit Publicity Code|
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.
A unique identifier assigned to the patient encounter.
|PV1^19^00149^Visit Number| |PV1^50^00180^Alternate Visit ID|
A type of medical management area in which care is scheduled to be delivered.
OpenIssue: This may need to be a repeating field with a type code to differentiate the entries to clarify scheduled, actual, administrative, etc. Clarify how this code is relevant to purpose_cd.
This field contains site-specific values that identify the type of patient, for example, outpatient surgery, inpatient short stay, etc.
OpenIssue: Current x-ref is from Patient Type and Patient Class. Should this be two attributes?
|FT1^18^00148^Patient Type| |PV1^2^00132^Patient Class| |PV1^18^00148^Patient Type|
A code depicting the purpose of the patient encounter.
The data and time the documentation of the patient encounter is signed.
A code identifying special courtesies extended to the patient. For example, no courtesies, extended courtesies, VIP 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, . . .).
The triage classification of the patient during an encounter.
Rationale: This attribute is related to an encounter rather than to the patient in general
A code depicting the urgency of the patient encounter.
|PV2^25^00726^Visit Priority Code|
Rationale: Allows removal of generalization (patient_clinical_item) with single specialization
Rationale: Establish independence of service events from encounters.
|
disclosure_dttm info_disclosed_desc info_requested_desc |
reason_cd requested_dttm urgency_cd |
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.
Interested committees Information Management (Medical Records)
A role played by the stakeholder. The role of the stakeholder is the recipient of patient information. The stakeholder is the person or organization to whom the patient information is being disclosed.
|
id |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Interested committees Patient Administration
A pool of like-type locations available for scheduling purposes.
Rationale: Currently in 2.3
OpenIssue:
Unique identifier for the group
Rationale: Currently in 2.3
OpenIssue:
|
type_cd |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Interested committees Patient Administration
Request information about specific locations that are controlled by a schedule
Rationale: Specializes the request by type of resource
OpenIssue: We must disambiguate the difference between Orders and Schedules
Identifies the role of the resource requested/scheduled for an appointment
Rationale: Creates a separate class for types of equipment
OpenIssue:
|AIG^3^00897^Resource ID|
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Interested committees Patient Administration
An allocation of time defined when a specific location is available for use for a healthcare service.
Rationale: future
OpenIssue:
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
An allocation of time defined when a patient is available to receive a healthcare service.
Rationale: future
OpenIssue:
Class steward is Patient Administration
Interested committees Orders/Observation
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.
Rationale: PAFM has received several requests to change birthplace from an ST to AD or XAD type.
|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| |NK1^22^00743^Publicity Indicator| |NK1^23^00744^Protection Indicator| |PD1^11^00743^Publicity Indicator| |PD1^12^00744^Protection Indicator|
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| |PID^30^00741^Patient Death Indicator|
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.
EXTREF: This information is reported on UB FL 15.
|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 the person's language.
Note that the domain definition folks can draw from is ISO639 language table.
|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.
This information is reported on UB FL 16
|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 attribute 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:
Represents the type of name, e.g., Alias, Legal, Display ...
Rationale: required by components of V2.3 field
OpenIssue:
The primary name of a person.
EXTREF: This information is reported on UB FL 12 when the person becomes a patient.
|DG1^16^00390^Diagnosing Clinician| |GT1^3^00407^Guarantor Name| |GT1^4^00408^Guarantor Spouse Name| |GT1^45^00748^Contact Person's Name| |IN1^6^00431^Insurance Co. Contact Person| |IN1^16^00441^Name of Insured| |IN2^9^00480^Champus Sponsor Name| |IN2^22^00493^Special Coverage Approval Name| |IN2^49^00789^Employer Contact Person Name| |IN2^52^00792^Insured’s Contact Person’s Name| |IN3^3^00504^Certified By| |IN3^8^00509^Operator| |IN3^14^00515^Physician Reviewer| |IN3^15^00516^Certification Contact| |IN3^21^00522^Case Manager| |IN3^25^00526^Second Opinion Physician| |NK1^2^00191^Name| |NK1^30^00748^Contact Person's 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 indication of the person's student status, for example, full-time student, part-time student, etc.
|GT1^40^00745^Student Indicator| |IN2^38^00745^Student Indicator| |NK1^24^00745^Student Indicator| |PD1^5^00745^Student Indicator|
An indication of the person's VIP type, for example, board member, diplomat, etc..
|PV1^16^00146^VIP Indicator|
|
cd effective_dt nm |
reason_cd termination_dt type_cd |
Class steward is Patient Administration
A additional name by which a person is or has been known.
An indication of the representation of the person's name. This attribute 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
The effective date of the person's alternate name.
Other names by which a person is known.
|IN2^7^00478^Medicaid Case Name| |PID^9^00112^Patient Alias|
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, . . .).
|
addr effective_dt hazard_exposure_txt job_class_cd job_status_cd job_title_nm occupation_cd |
phon protective_equipment_txt salary_amt salary_type_cd status_cd termination_dt |
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.
EXTREF: This information is reported on UB92 FL 66.
|GT1^17^00421^Guarantor Employer Address| |IN1^44^00469^Insured's Employer Address| |NK1^4^00193^Address|
The date the person's employment begins.
|GT1^31^00782^Guarantor Hire Effective Date| |IN2^44^00787^Insured's Employment Start Date|
The type of hazards a person is exposed to in their employment.
A code depicting the employee classification, for example, full-time, part-time.
Rationale: The job class in v2.3 (second component of JCC data type) references Employee Classification table. The first component of the JCC data type (job code) is represented in Person_employment.job_cd.
OpenIssue: What is the difference in the job class (employee classification table) vs Employment status in GT1-20 and IN1-42?
|GT1^50^00786^Job Code/Class| |IN2^47^00786^Job Code/Class| |NK1^11^00200^Next of Kin/Associated Parties Job Code/Class| |STF^19^00786^Job Code/Class|
This field identifies the person's job status. For example, leave of absence, suspended.
|GT1^53^00752^Job Status| |IN2^48^00752^Job Status| |NK1^34^00752^Job Status|
The title of the job held, for example, Vice President, Senior Technical Analyst.
|GT1^49^00785^Job Title| |IN2^23^00494^Special Coverage Approval Title| |IN2^46^00785^Job Title| |NK1^10^00199^Next of Kin/Associated Parties Job Title| |STF^18^00785^Job Title|
A code depicting the occupation of the person, for example, accountant, programmer, banker.
Rationale: Represents the first component of the JCC data type (job Code)
|GT1^50^00786^Job Code/Class| |IN2^47^00786^Job Code/Class| |NK1^11^00200^Next of Kin/Associated Parties Job Code/Class| |STF^19^00786^Job Code/Class|
The telephone number of a person at the person's place of employment.
|GT1^7^00411^Guarantor Ph Num-Business| |IN2^64^00804^Insured’s Employer Telephone Number| |NK1^6^00195^Business Phone Number| |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.
EXTREF: This information is reported on UB92 FL 64.
|GT1^20^00424^Guarantor Employment Status| |IN1^42^00467^Insured's Employment Status|
Date the person's employment ends.
|GT1^32^00783^Guarantor Employment Stop Date| |IN2^45^00783^Guarantor Employment Stop Date|
|
authorized_encounters_amt authorized_period_begin_dt authorized_period_end_dt id issued_dttm |
requested_dttm restriction_desc status_cd status_change_dttm |
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.
Rationale: IN1-28
OpenIssue:
|IN1^28^00453^Pre-Admit Cert (PAC)|
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.
|
effective_dt role_cd |
termination_dt |
Class steward is Patient Administration
An association between a patient and a healthcare provider. The healthcare provider may be either an individual (e.g., primary care physician) or an organization (e.g., a clinic).
The date that the provider becomes the preferred care provider for the patient.
Rationale: Requested addition to V2.3.1.
A code describing the relationship between the patient and their preferred provider (e.g., internist, pediatrician, or gynecologist when the relationship is to an individual healthcare practitioner; oncology clinic when the relationship is to a healthcare provider organization).
The last date that the provider is the preferred provider for the patient.
Rationale: Requested additional to v2.3.1.
Rationale: A person's PCP can be either a practitioner or a provider organization.
|
anesthesia_cd anesthesia_minutes_qty delay_reason_txt incision_closed_dttm incision_open_dttm modifier_cd |
priority_amt procedure_cd procedure_dttm procedure_functional_type_cd procedure_minute_qty |
Class steward is Orders/Observation
Interested committees Patient Administration
A therapeutic or diagnostic intervention employed in response to a patient condition.
OpenIssue: We are not sure if the gen-spec relationship should be moved from Procedures is_specialization of Service_event to Procedure is_specialization of Care_event or not. The data seems to be needed, but it is not definite where in the model they should go. It needs further work. Many of these attributes have come from the UBforms, and have not yet been properly modeled. More work by PAFM and OO is needed.
A code identifying the anesthesia 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.
Codes, typically defined by regulatory agencies such as HCFA or the AMA, that modify the procedure code.
Rationale: Regulatory requirement, requested addition to v2.3.1.
OpenIssue: Note that we have an open question about all the attributes that are coded in that we currently have not way in which to specify the value domains that they should be drawn from.
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.
|CDM^7^00393^Procedure Code| |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 Functional Type|
The length of the procedure, measured in minutes.
|PR1^7^00397^Procedure Minutes|
Rationale: Add Procedure as possible source of specimen.
|
service_producing_department_type_cd |
Class steward is Orders/Observation
Interested committees Patient Administration
The person or organization that offers to provide this service to the patient.
Rationale: support use of Producer ID in V2.3 OM1
OpenIssue: General consensus that we would like a more robust definition. There is a question as to whether or not this has anything to do with being authorized to do the service. There is v2.3 ambiguity that we need to fix. Unclear if it is the name of a lab?
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:
|
authorized_visits_qty desc |
reason_txt |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Interested committees Patient Administration
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.
|
allowable_substitutions_cd duration_qty start_dttm |
start_offset_qty status_cd |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Individual resource request information about various kinds of resources that are controlled by a schedule.
Rationale: Currently in 2.3
OpenIssue:
A code indicating whether the identified resource can be substituted with an equivalent resource.
Rationale: Currently in 2.3
OpenIssue:
|AIG^13^00895^Allow Substitution Code| |AIL^11^00895^Allow Substitution Code| |AIP^11^00895^Allow Substitution Code| |AIS^9^00895^Allow Substitution Code|
The duration for which the resource is requested for this appointment, if it is different than the overall duration of the appointment
Rationale: Currently in 2.3
OpenIssue:
|AIG^11^00893^Duration| |AIL^9^00893^Duration| |AIP^9^00893^Duration| |AIS^7^00893^Duration|
Date and time this resource is requested for the appointment.
Rationale: Currently in 2.3
OpenIssue:
|AIG^8^01202^Start Date/Time| |AIL^6^01202^Start Date/Time| |AIP^6^01202^Start Date/Time| |AIS^4^01202^Start Date/Time|
The offset that this resource is requested for the appointment, expressed in units of time relative to the scheduled start date/time of the appointment.
Rationale: Currently in 2.3
OpenIssue:
A code that describes the request status of scheduling a resource or activity, from the point of view of the filler application.
Rationale: Currently in 2.3
OpenIssue:
|AIG^14^00889^Filler Status Code| |AIL^12^00889^Filler Status Code| |AIP^12^00889^Filler Status Code| |AIS^10^00889^Filler Status Code| |SCH^25^00889^Filler Status Code|
|
offset_qty quantity_amt resource_type_cd |
slot_state_cd start_dttm |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
An allocation of time on a schedule for a resource that must be reserved prior to its use.
Rationale: Currently in 2.3
OpenIssue:
Offset from start date and time when this allocated use will begin
Rationale: future
OpenIssue:
Number of slots allocated to a given purpose
Rationale: future
OpenIssue:
Type of resource controlled by this set of slots: provider, location, or equipment.
Rationale: future
OpenIssue:
Current status for this set of slots: available, booked, or blocked.
Rationale: future
OpenIssue:
Start date and time for this set of slots
Rationale: future
OpenIssue:
Links a schedule to its contents.
|
incident_cd incident_dttm |
incident_severity_cd incident_type_cd |
Class steward is Patient Administration
Interested committees Orders/Observation
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, . . .).
|
id |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
A set of open, booked, and blocked slots for one or more resources.
Rationale: Currently in 2.3
OpenIssue:
Unique identifier for a Schedule.
Rationale: Currently in 2.3
OpenIssue: Needs to be further fleshed out. Is it needed as a class if it is this thin?
|ARQ^5^00864^Schedule ID| |SCH^5^00864^Schedule ID|
Class steward is Orders/Observation
Interested committees Patient Administration
The performance of a health related action provided by one or more active participants on behalf of one or more target participants.
This includes medical as well as non-medical services. A patient can be both target and active participant of the service: - a clinical test - an assessment of health condition (such as problems and diagnoses), - the setting of healthcare goals - the performance of treatment services, such as medication, surgery, physical and psychological therapy. - assisting, monitoring or attending - training and education services to patients and their next of kins - notary services, such as advanced directives or living will
Examples of active participants are nurses, doctors, family members, and notary publics. Target participants may include, the patient, the patient's spouse, family, or community, a specimen drawn from the patient or from any object of interest. As patients do play active roles in their own healthcare, the patient can be both an active participant and a target participant at the same time (self-administered or reflexive services.) A service_event can have multiple active participants and multiple target participants, their specific role is distinguished in the "type_cd" of the respective instance of the participation class (see there [HREF]).
The service_event is the documentation of a rendered service including its detailed context, as opposed to the formulation of an intended service. A service event includes the "results," "answers" or "procedure products" gained during the service. In this model, "results" do not exist without a service, and every clinical result, including those results gained accidentially, are service_events.
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.
Rationale: To support the Problem requirement for specificity of attestation timing.
|DG1^19^00768^Attestation Date/Time|
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 entity 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 entity for the studies performed when applicable.
Rationale: previously unmatched V2.3 field
OpenIssue:
|OBR^23^00256^Charge To Practice|
An indication that the diagnosis is confidential.
|DG1^18^00767^Confidential Indicator| |DRG^10^00767^Confidential Indicator|
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.
The end date and time for the patient service.
|OBR^8^00242^Observation End Date/Time| |RXA^4^00346^Date/Time End of Administration|
Indicates the individual's family or significant other's comprehension of the service event.
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|
This field contains the individual's comprehension of the service event (e.g., full, marginal, partial, etc.).
OpenIssue: Is this code or text? Should this be renamed to Patient_awareness_cd?
Indicates whether patient considers this service to be confidential.
Rationale: Code data type allows more structure to the representation of confidentiality. The use of the word "sensitivity" parallels usage in class Problem
|DG1^18^00767^Confidential Indicator| |DRG^10^00767^Confidential Indicator|
A code indicating a recurring service and the nature of the recursion.
|PV2^31^00732^Recurring Service Code|
The date the patient service is scheduled to begin.
|OBR^36^00268^Scheduled Date/Time|
Text that describes the service performed along with relevant details of the service.
Rationale: To differentiate this attribute from Service_event: service_event_desc.
A description of the service event.
A code depicting the action taken upon the specimen in the context of a service event.
Rationale: Each service event uses only one specimen. Reflects current usage of "specimen" rather than "analyzed object."
The data and time the specimen was received for use in the service event.
Rationale: Each service event uses only one specimen.
|OBR^14^00248^Specimen Received Date/Time|
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.
Rationale: Establish independence of service events from encounters.
Rationale: Establish Service_event as the evidence for a Service_reason.
Rationale: Establish Service_reason as the reason for a Service_event.
|
relationship_type_cd |
Class steward is Orders/Observation
A recursive class that creates groupings of items in Service_event that define various relationship types, including but not limited to "battery" and "temporal distribution."
Rationale: Routine order sets, clinical trials, and pathways require groupings of services such as panels or "batteries" of unlike tests delivered at one time, grouping of the same tests delivered along a timeline, or grouping of a combination of these concepts. The same grouping relationships captured in the Master_service need to be maintained as the service is delivered.
Specifies the basis for the association of the source to the target.
Rationale: Relationship management.
Class steward is Orders/Observation
The instantiation of the intent or request to perform a particular service as represented in Master_service particular date for a particular patient by a particular provider.
Rationale: This class adds the ability to attach context information and modify default values as a plan for a particular target of service that is to receive a service itemized in the Master_service catalog.
OpenIssue: This name does not conform to the style guide.
Note: An additional attribute to identify each instance of this class is either an order or an intent must be added to this proposal. Both PC and OO agree to the additional attribute. See U004.21.
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|
Time expected to perform this service instance for the target.
Rationale:
OpenIssue:
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|
Distinguishes an intent from an order.
Rationale: There exists reasons that require being able to distinguish the two types of instances.
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 supposed 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
|ARQ^4^00218^Placer Group Number| |ORC^4^00218^Placer Group Number| |SCH^4^00218^Placer Group Number|
A unique identifier for the patient service order.
|FT1^23^00217^Filler Order Number| |OBR^2^00216^Placer Order Number| |OBR^3^00217^Filler Order Number| |ORC^2^00216^Placer Order Number| |ORC^3^00217^Filler Order Number| |TXA^14^00216^Placer Order Number| |TXA^15^00217^Filler Order Number|
The date and time the order was placed.
Rationale: To provide date-time precision required for representing pathways.
|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 differentiate 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|
Status of results for this intent or order.
Rationale: alignment with V2.3 name. missing definition in RIM08. This attribute represents the overall status of all observations for the request. Since each service event represents only a single observation, the status of all observations for an intent or order must be represented in the intent or order itself.
OpenIssue:
|OBR^25^00258^Result Status|
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|
Object which is target of the service
Rationale: This is not necessarily the patient.
OpenIssue: In order to make this consistent, Orders must move Processing_time and Typical_turnaround_time from the Master_observation_service to this class.
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 and 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|
Rationale:
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: Establish Service_reason as the reason for a Service_intent_or_order.
Rationale: supports use of BLG segment in the ORM message
OpenIssue: Open issue: needs joint work with OO-PAFM
Rationale: previously unmatched V2.3 field
OpenIssue:
|
constraint_txt quantitytiming_qt |
reflex_testing_trigger_rules_desc relationship_type_cd |
Class steward is Orders/Observation
Associates a composite or dependent intent or order (the target) with another intent or order (the source) which is related to the target in some way. Allows specification of constraints for each association.
Rationale: Routine order sets, clinical trials, and pathways require groupings of services such as panels or "batteries" of unlike tests delivered at one time, the same tests delivered along a timeline, or a combination of these concepts. The same grouping relationships captured in the Master_service need to be maintained as the service is planned or ordered.
Textual description of any arbitrary constraint on the source when associated with the target.
Rationale: Details of a possible relationship between services.
A means of qualifying the relationship between a source and a target Service_intent_or_order, specifying when the source service is to be performed and how frequently. It is a complex multicomponent field that can have repeats. If a specimen is required for the source service, the Priority component contains specimencollection priority rather than processing priority.
Rationale: This will be enhanced by the committee to cover all data items required by the quantity timing data type in Version 2.x.
A description of the rules that trigger reflex testing for an intended or ordered service.
Rationale: Detail of a possible relationship between services.
Specifies the basis for the association of the source to the target.
Rationale: Relationship management
|
determination_dttm documentation_dttm |
reason_txt |
Interested committees Patient Care
A class which captures the reason(s) for a service when instantiated for a particular target of service by a particular participant in the service e.g., a free text reason, coded value(s), or associations with prior service_event(s).
Rationale: Regulatory agencies demand reasons for services e.g., 1500 billing forms. Frequently, a prior observation is the reason for a treatment or a prior treatment is the reason for an observation.
The date and time at which the determination is made that the reason applies.
Rationale: Required to manage reasons.
The date and time at which the applicability of the reason is document.
Rationale: Required to manage reasons.
Capture free text for the reason for a service event when the connection to another service event is not known (connection as a reason).
Rationale: Establish Service_event as the evidence for a Service_reason.
Rationale: Establish Service_reason as the reason for a Service_event.
Rationale: Establish Service_reason as the reason for a Service_intent_or_order.
|
allowable_substitutions_cd duration_qty start_dttm |
start_offset_qty status_cd |
Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
Interested committees Orders/Observation
Request information about various kinds of services that are controlled by a schedule.
Rationale: Currently in 2.3
OpenIssue: Should services be handled separately from resources? Make certain that resource requests for scheduling are different from ordered service requests in Orders.
OpenIssue: The definition does not encompass notifications (where it is not a request).
A code indicating whether the identified service can be substituted with an equivalent service.
Rationale: Currently in 2.3
OpenIssue:
|AIG^13^00895^Allow Substitution Code| |AIL^11^00895^Allow Substitution Code| |AIP^11^00895^Allow Substitution Code| |AIS^9^00895^Allow Substitution Code|
The duration for which the service is requested for this appointment, if it is different than the overall duration of the appointment
Rationale: Currently in 2.3
OpenIssue:
|AIG^11^00893^Duration| |AIL^9^00893^Duration| |AIP^9^00893^Duration| |AIS^7^00893^Duration|
Date and time this service is requested for the appointment.
Rationale: Currently in 2.3
OpenIssue:
|AIG^8^01202^Start Date/Time| |AIL^6^01202^Start Date/Time| |AIP^6^01202^Start Date/Time| |AIS^4^01202^Start Date/Time|
The offset that this service is requested for the appointment, expressed in units of time relative to the scheduled start date/time of the appointment.
Rationale: Currently in 2.3
OpenIssue:
|AIG^9^00891^Start Date/Time Offset| |AIL^7^00891^Start Date/Time Offset| |AIP^7^00891^Start Date/Time Offset| |AIS^5^00891^Start Date/Time Offset|
A code that describes the request status of scheduling a service, from the point of view of the filler application.
Rationale: Currently in 2.3
OpenIssue:
|AIG^14^00889^Filler Status Code| |AIL^12^00889^Filler Status Code| |AIP^12^00889^Filler Status Code| |AIS^10^00889^Filler Status Code| |SCH^25^00889^Filler Status Code|
|
addr credit_rating_cd email_address_txt |
phon type_cd |
Class steward is Patient Administration
Interested committees Orders/Observation
A person or organization that has an investment, share, or interest in healthcare.
The address of a stakeholder.
|GT1^5^00409^Guarantor Address| |GT1^17^00421^Guarantor Employer Address| |IN1^5^00430^Insurance Company Address| |IN1^19^00444^Insured's Address| |IN1^44^00469^Insured's Employer 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.
|GT1^6^00410^Guarantor Ph Num- Home| |GT1^7^00411^Guarantor Ph Num-Business| |GT1^18^00422^Guarantor Employer Phone Number| |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, . . .).
|GT1^10^00414^Guarantor Type|
|
family_relationship_cd |
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| |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|
|
affiliation_type_cd desc |
effective_dt termination_dt |
Class steward is Patient Administration
Interested committees Orders/Observation
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|
|
effective_dt id identifier_type_cd |
issued_dt qualifying_information_txt termination_dt |
Class steward is Patient Administration
Interested committees Orders/Observation
A unique identifier assigned to a person or organization.
The effective date of the identifier.
A unique identifier assigned to a stakeholder.
|FT1^13^00367^Department Code| |FT1^20^00372^Performed By Code| |FT1^21^00373^Ordered By 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| |GT1^42^00746^Mother’s Maiden Name| |IN1^3^00428^Insurance Company ID| |IN1^8^00433^Group Number| |IN1^10^00435^Insured's Group Emp ID| |IN2^1^00472^Insured's Employee ID| |IN2^2^00473^Insured's Social Security Number| |IN2^4^00475^Employer Information Data| |IN2^10^00481^Champus ID Number| |IN2^25^00496^Payor ID| |IN2^26^00497^Payor Subscriber ID| |IN2^40^00746^Mother’s Maiden Name| |IN2^61^00801^Patient Member Number| |IN2^70^00810^Insured Employer Organization Name And ID| |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| |NK1^26^00746^Mother’s Maiden Name| |OBR^10^00244^Collector Identifier| |OBR^16^00226^Ordering Provider| |OBR^28^00260^Result Copies To| |OBR^32^00264^Principal Result Interpreter| |OBR^33^00265^Assistant Result Interpreter| |OBR^34^00266^Technician| |OBR^35^00267^Transcriptionist| |OBX^15^00583^Producer's ID| |OBX^16^00584^Responsible Observer| |OM1^5^00590^Producer ID| |ORC^10^00224^Entered By| |ORC^11^00225^Verified By| |ORC^12^00226^Ordering Provider| |ORC^17^00231^Entering Organization| |ORC^19^00233^Action By| |PID^2^00105^Patient ID (External ID)| |PID^3^00106^Patient ID (Internal ID)| |PID^4^00107^Alternate Patient ID - PID| |PID^6^00746^Mother’s Maiden Name| |PID^19^00122^SSN Number - Patient| |PID^20^00123^Driver's Licence Number-Patient| |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/Treatment Supplier's Verifier ID| |RXO^14^00305^Ordering Provider's DEA Number| |RXO^15^00306^Pharmacist/Treatment Supplier's Verifier ID|
A code identifying the type of identifier. For example, codes to represent the US National Provider ID, US National Payor ID, US Health Care ID, medical record number, social security number.
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|
The date the identification is no longer in effect.
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begin_dttm duration_tm |
end_dttm participation_type_cd |
Class steward is Orders/Observation
A role class that captures the various roles played by the recipient(s) of a service (including people, organizations, things, animals, etc.).
Rationale: Since multiple entities may participate in the reception of services as particular targets of a service, a role class is needed to capture the multiple roles these participants play in receiving a service from a provider of a service.
The effective date and time of the target participation.
Rationale: Manage target participatiions.
The elapsed time during which the target participation is in effect.
Rationale: Manage target participations.
The termination date and time for the target participation.
Rationale: Manage target participations.
The nature of purpose of the target's participation. Examples: subject, beneficiary, receiver, user, specifier.
Rationale: Manage target participations.
Rationale: Replaces associations: Patient may_be_the_subject_of order - Patient is_subject_of Clinical_observation - Patient has Goal.
Rationale: Replaces association Collected_specimen_sample is_used_during Service_event.
Rationale: replaces associations: Patient_service_location receives Treatment_service_dispense - Patient_service_location receives_medication_dispense_recorded_on Treatment_service_give - Patient_service_location receives_medication_delivery_specified_on Treatment_intent_or_order_revision.
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
An authoritative direction or instruction concerning the dispensement of medication to a patient.
Rationale: Conformance to new name for generalization.
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/Treatment 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. Conformance to new name for generalization.
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, e.g., 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: link medication on pharmacy_service_order_item to service catalog
OpenIssue:
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administered_rate_txt completion_status_cd substance_refusal_reason_cd |
substitution_cd system_entry_dttm |
Class steward is Orders/Observation
Actual administration of medication as part of a pharmacy treatment.
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)|
Status of treatment administration event
Rationale: previously unmatched V2.3 field
OpenIssue:
|RXA^20^01223^Completion Status|
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|
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dispense_package_method_cd dispense_package_size_amt needs_human_review_ind rejection_reason_txt |
substitution_cd suppliers_special_dispensing_instruction_cd total_daily_dose_amt |
Class steward is Orders/Observation
Notification of a pharmacy treatment dispense.
the method by which treatment is dispensed, e.g., 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|
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.
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|
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expiration_dttm indication_cd notes_txt prescription_id PTcomp |
PTrout refills_remaining_qty substance_lot_number_txt substance_manufacturer_cd |
Class steward is Orders/Observation
A type of service event in which a pharmacy or treatment service is performed.
Expiration date of the medication.
Rationale: alignment with V2.3 language. Common to all specializations of Treatment_service.
This field contains the identifier of the condition or problem for which the treatment service was established.
Rationale: previously unmatched V2.3 field. Common to all specializations of Treatment_service.
OpenIssue:
|RXA^19^01123^Indication| |RXD^21^01123^Indication| |RXG^22^01123^Indication| |RXO^20^01123^Indication|
Free form text notes to the person performing the treatment service.
Rationale: alignment with V2.3 language; although V2.3 field is CE datatype, CE no longer supports free text in V3.0. Common to all specializations of Treatment_service.
|RXD^9^00340^Dispense Notes|
An identifier assigned to the pharmacy treatment service event.
|RXD^7^00325^Prescription Number| |RXE^15^00325^Prescription Number|
Specification for one route of administration for the treatment service. Specification includes route, site, administration device and administration method.
Rationale: Common to all specializations of Treatment_service.
OpenIssue:
|RXC^4^00316^Component Units|
Specification for one component of the treatment service.
Rationale: Common to all specializations of Treatment_service.
OpenIssue:
|RXR^3^00311^Administration Device|
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|
This field contains the lot number of the medical substance.
Rationale: alignment with V2.3. Common to all specializations of Treatment_service.
|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.
Rationale: previously unmatched V2.3 field. Common to all specializations of Treatment_service.
OpenIssue:
|RXA^17^01131^Substance Manufacturer Name| |RXD^20^01131^Substance Manufacturer Name| |RXG^21^01131^Substance Manufacturer Name|
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administration_desc give_per_time_unit_cd give_quantitytiming_qt give_rate_amt max_give_amt |
min_give_amt needs_human_review_ind substitution_status_cd supplier_special_administration_instruction_cd |
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's Special Administrati|
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)|
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|
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|
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's Special Administrati|
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Advance_directive Authentication Clinical_document_header Consent |
Document_recipient Health_chart Health_chart_deficiency Healthcare_document_authenticator |
Notary_public Originator Transcriptionist |
|
Condition_node Episode |
Goal |
Health_issue |
|
Clinical_observation |
Patient_information_recipient |
|
Service_reason |
Service_scheduling_request |