Class: Clinical_document_header

Description of: Clinical_document_header

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.

Attribute definitions for: Clinical_document_header

authentication_dt

The date the document was authenticated.

availability_status_cd

A code depicting the availability of the document.

change_reason_cd

A code depicting the reason for the latest change to the document.

completion_status_cd

A code depicting the completion status of the document.

confidentiality_status_cd

A code depicting the confidentiality status of the document.

content_presentation_cd

A code indicating how the content of the document is to be presented.

document_header_creation_dt

The specific date that the document header was created..

file_nm

The name on an electronic file containing the document.

id

A unique identifier assigned to the document.

last_edit_dt

The date the document was last edited.

origination_dt

The date the information in the document was originated.

reporting_priority_cd

The reporting priority of the clinical result.

|OM1^26^00611^Reporting Priority|

results_report_dttm

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|

storage_status_cd

A code depicting the storage status of the document.

transcription_dt

The date the information in the document was transcribed.

type_cd

A code depicting the document type.

Association definitions for: Clinical_document_header

has_as_a_parent_document (0,1) :: Clinical_document_header :: is_parent_document_for (0,n)

has_been_originated_by (0,1) :: Originator :: of (0,n)

is_transcribed_by (0,1) :: Transcriptionist :: transcribes (0,n)

is_related_to (0,1) :: Service_intent_or_order :: may_be_referred_to_in (0,n)

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.

has_been_received_by (0,1) :: Document_recipient :: of (0,n)

is_parent_document_for (0,n) :: Clinical_document_header :: has_as_a_parent_document (0,1)

may_be_contained_in (0,1) :: Health_chart :: contains (0,n)

is_related_to (0,n) :: Authentication :: is_related_to (1,1)

documents (0,n) :: Service_event :: is_documented_by (0,n)