DRAFT HL7 Reference Information Model

Link to Subjects
Link to Stewardship and Class interests and DIMs
This data model was HTML encoded by software prepared for the HL7-CDM. Comments on presentation links or any bugs encountered may be addressed to:
beeler@mayo.edu
(George Beeler).

Identifications:

Organization: Health Level Seven
Version: V 0-86 19980906
Developed by: Modeling and Methodology

Subjects in: DRAFT HL7 Reference Information Model

Subject Area: RIM_Clinical_pathway_master

A collection of master tables related to clinical pathways.

Subject Area: RIM_Guarantor_contract

A collection of classes related to a guarantor contract.

Subject Area: RIM_Healthcare_benefit_plan

A collection of classes related to healthcare benefit plans.

Subject Area: RIM_Healthcare_finances

A collection of subject areas related to the financial aspects of Healthcare.

Subject Area: RIM_Healthcare_service_provider

A collection of classes related to Healthcare service providers.

Subject Area: RIM_Healthcare_stakeholders

A collection of subject areas related to healthcare stakeholders.

Subject Area: RIM_Master_tables

A collection of classes designated used as reference classes to master tables.

Subject Area: RIM_Observation_service_catalog_item

A collection of classes describing observation service types.

Subject Area: RIM_Organization

A collection of classes related to organizational stakeholders.

Subject Area: RIM_Patient

A collection of subject areas related to patients.

Subject Area: RIM_Patient_billing_account

A collection of classes related to the patient billing account.

Subject Area: RIM_Patient_clinical_pathway

A collection of classes related to patient specific clinical pathways or treatment plans.

Subject Area: RIM_Patient_encounter

A collection of classes related to patient encounters.

Subject Area: RIM_Patient_encounters

A collection of subject areas related to patient encounters and patient services

Subject Area: RIM_Patient_service_event

A collection of classes related to the patient service events.

Subject Area: RIM_Patient_service_location

A collection of classes related to location of patient services.

Subject Area: RIM_Patient_service_order

A collection of classes related to patient service orders.

Subject Area: RIM_Person

A collection of classes related to person stakeholder.

Subject Area: RIM_Pharmacy_service_event

A collection of services related to pharmacy treatment service events.

Subject Area: RIM_Scheduling

A collection of classes related to scheduling patients and resources.

Subject Area: RIM_Service_catalog_item

A collection of classes related to service catalog items.

Subject Area: RIM_Stakeholder

A collection of classes in related to stakeholders.

Subject Area: RIM_unassigned

Subject Area: All_Classes

  • Accident_information_source
  • Active_participation
  • Administrative_birth_event
  • Administrative_diagnosis
  • Administrative_patient_accident
  • Administrative_patient_death
  • Advance_directive
  • Allergy
  • Appointment
  • Appointment_contact_person
  • Appointment_request
  • Assessment
  • Authentication
  • Bad_debt_billing_account
  • Bad_debt_collection_agency
  • Billing_information_item
  • Care_event
  • Certification_second_opinion
  • Champus_coverage
  • Clinical_document_header
  • Clinical_observation
  • Collected_specimen_sample
  • Consent
  • Contact_person
  • Diagnostic_related_group
  • Dietary_intent_or_order
  • Disability
  • Document_recipient
  • Durable_medical_equipment
  • Durable_medical_equipment_group
  • Durable_medical_equipment_request
  • Durable_medical_equipment_slot
  • Employee
  • Employer
  • Encounter_drg
  • Encounter_practitioner
  • Episode
  • Financial_transaction
  • Goal
  • Guarantor
  • Guarantor_contract
  • Health_benefit_plan_purchaser
  • Health_chart
  • Health_chart_deficiency
  • Healthcare_benefit_plan
  • Healthcare_benefit_service
  • Healthcare_coverage_benefit
  • Healthcare_document_authenticator
  • Healthcare_provider_organization
  • Healthcare_service_provider
  • Identifier_issuing_authority
  • Individual_healthcare_practitioner
  • Individual_healthcare_provider_group
  • Individual_healthcare_provider_request
  • Individual_healthcare_provider_slot
  • Inpatient_encounter
  • Insurance_certification
  • Insurance_certification_contact
  • Insurer
  • Location_encounter_role
  • Master_calculated_observation
  • Master_categorical_observation
  • Master_continuous_observation
  • Master_numeric_range
  • Master_observation_service
  • Master_service
  • Master_service_relationship
  • Master_specimen_requirement
  • Master_treatment_service
  • Medicaid_coverage
  • Medicare_coverage
  • Notary_public
  • Observation_intent_or_order
  • Organization
  • Originator
  • Patient
  • Patient_admission
  • Patient_appointment_request
  • Patient_arrival
  • Patient_billing_account
  • Patient_departure
  • Patient_encounter
  • Patient_information_disclosure
  • Patient_information_recipient
  • Patient_service_location
  • Patient_service_location_group
  • Patient_service_location_request
  • Patient_service_location_slot
  • Patient_slot
  • Person
  • Person_alternate_name
  • Person_employment
  • Preauthorization
  • Preferred_provider_participation
  • Problem
  • Procedure
  • Producer_of_master_service
  • Referral
  • Resource_request
  • Resource_slot
  • Risk_management_incident
  • Schedule
  • Service_event
  • Service_event_relationship
  • Service_intent_or_order
  • Service_intent_or_order_relationship
  • Service_reason
  • Service_request
  • Stakeholder
  • Stakeholder_affiliate
  • Stakeholder_affiliation
  • Stakeholder_identifier
  • Target_participation
  • Transcriptionist
  • Treatment_intent_or_order
  • Treatment_intent_or_order_revision
  • Treatment_service_administration
  • Treatment_service_dispense
  • Treatment_service_event
  • Treatment_service_give
  • Description of: DRAFT HL7 Reference Information Model

    This draft HL7 Reference Information Model (RIM) is the result of the third HL7 RIM harmonization cycle, and includes all technical corrections from that cycle. RIM change proposals from several HL7 Technical Committees were reviewed and acted upon during a RIM Harmonization Meeting held June 24-25, 1998 in Boston, MA, and the technical corrections were applied during the third week of August and the first week of September, 1998.

    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


    Classes in: DRAFT HL7 Reference Information Model

    Class: Accident_information_source

    Description of: Accident_information_source

    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.

    Connection definitions for: Accident_information_source

    is_the_source_of (0,n) :: Administrative_patient_accident :: is_obtained_from (0,1)

    is_a_role_of (1,1) :: Stakeholder :: takes_on_role_of (0,1)

    Class: Active_participation

    Description of: Active_participation

    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.

    Attribute definitions for: Active_participation

    begin_dttm

    The effective and time of the active participation.

    Rationale: Manage active participations.

    duration

    The elapsed time during which the active participation is in effect.

    Rationale: Manage active participations.

    end_dttm

    The termination date and time for the active participation.

    Rationale: Manage active participations.

    participation_type_cd

    The nature or purpose of the participant's participation. Examples: order healthcare practitioner, service event provider, advance directive witness, notarizer.

    Rationale: Manage active participations.

    Connection definitions for: Active_participation

    has_as_participant (0,1) :: Stakeholder :: participates_in (0,n)

    participates_in (0,1) :: Service_event :: has_as_active_participant (0,n)

    participates_in (0,1) :: Service_intent_or_order :: has_as_participant (0,n)

    Class: Administrative_birth_event

    Description of: Administrative_birth_event

    Class steward is Patient Administration
    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.

    Attribute definitions for: Administrative_birth_event

    baby_detained_ind

    An indication that the baby in a person birth event is detained after the mother's discharge.

    |PV2^37^00738^Baby Detained Indicator|

    birth_certificate_id

    A unique identifier assigned to a person's birth certificate.

    birth_method_cd

    A code depicting the method of birth (e.g., caesarean, vaginal, forceps, . . .).

    birth_recorded_county_cd

    The county in which the person's birth record is recorded.

    birth_recorded_dt

    The date the birth event was recorded.

    newborn_days_qty

    The number of days in a patient encounter in which there is a person birth event that is allocated to the newborn.

    stillborn_ind

    An indication that the baby in the birth event was stillborn.

    Connection definitions for: Administrative_birth_event

    pertains_to (1,1) :: Person :: has (0,1)

    Whole-part definitions for: Administrative_birth_event

    is_part_of (1,1) :: Patient_encounter :: has_parts (0,n)

    Class: Administrative_diagnosis

    Description of: Administrative_diagnosis

    Class steward is Patient Care
    Interested committees Patient Administration
    The decision reached from the process of determining by examination the nature and circumstances of a diseased condition.

    Attribute definitions for: Administrative_diagnosis

    classification_type_cd

    A primary classification of diagnosis.

    |DG1^17^00766^Diagnosis Classification|

    confidential_ind

    An indication that the diagnosis is confidential.

    |DG1^18^00767^Confidential Indicator| |DRG^10^00767^Confidential Indicator|

    desc

    Free form description of the diagnosis.

    determination_dttm

    Date and time the diagnosis was determined.

    diagnosis_cd

    A unique identifier designating the diagnosis.

    |FT1^19^00371^Diagnosis Code| |PR1^15^00772^Associated Diagnosis Code|

    diagnosis_onset_dttm

    The date the decease indicated in the diagnosis became present in the patient.

    |DG1^5^00379^Diagnosis Date/Time|

    diagnosis_phase_cd

    The diagnostic phase code.

    employment_related_ind

    An indication that the diagnosis is employment related.

    Rationale: To replace attribute previously inherited by Diagnosis from Patient_clinical_item

    identification_cd

    The diagnosis identification code.

    |DG1^2^00376^Diagnosis Coding Method|

    relative_priority_nbr

    The relative priority of the diagnosis.

    |DG1^15^00389^Diagnosis Priority|

    rule_out_dttm

    The data and time the diagnosis was ruled out.

    ruled_out_reason_txt

    The reason the diagnosis was ruled out.

    severity_cd

    A code depicting the severity of the diagnosis.

    type_cd

    A classification type of diagnosis (e.g., admitting, working, discharge, . . .).

    |DG1^6^00380^Diagnosis Type|

    Class: Administrative_patient_accident

    Description of: Administrative_patient_accident

    Class steward is Patient Administration
    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.

    Attribute definitions for: Administrative_patient_accident

    accident_death_ind

    An indication that the accident resulted in death.

    Rationale: specific to this usage; alignment with V2.3 language

    |ACC^6^00814^Accident Death Indicator|

    accident_desc

    Free form textual description of the accident.

    accident_dttm

    The date and time the accident occurred.

    Rationale: alignment with V2.3 language

    |ACC^1^00527^Accident Date/Time|

    accident_location_desc

    A description of the location of the accident.

    Rationale: specific to this usage

    |ACC^3^00529^Accident Location|

    accident_state_cd

    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|

    accident_type_cd

    A code depicting the type of accident.

    |ACC^2^00528^Accident Code|

    assessment_dttm

    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|

    job_related_accident_ind

    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|

    Connection definitions for: Administrative_patient_accident

    is_obtained_from (0,1) :: Accident_information_source :: is_the_source_of (0,n)

    is_present_in (1,n) :: Patient_encounter :: has (0,n)

    Rationale: Allows removal of generalization (patient_clinical_item) with single specialization

    pertains_to (1,1) :: Patient :: has (0,n)

    Class: Administrative_patient_death

    Description of: Administrative_patient_death

    Class steward is Patient Administration
    The act of dying; the end of life; the total and permanent cessation of all the vital functions of a patient.

    Rationale: Better reflection of the administrative nature of this class.

    Attribute definitions for: Administrative_patient_death

    death_certificate_id

    The identifier assigned to the death certificate.

    death_certificate_recorded_dt

    The date that the death certificate is recorded.

    death_classification_cd

    A major classification of the cause of death.

    death_dttm

    The date and time of death.

    death_location_nm

    The name of the location where the death occurred.

    death_notification_source_nm

    The name of the source providing the death notification.

    death_verification_cd

    A code identifying the source type used for verification.

    death_verification_dt

    The date the death information is verified.

    death_verification_nm

    Name of the person providing verification of death.

    Connection definitions for: Administrative_patient_death

    pertains_to (1,1) :: Patient :: has (0,1)

    Class: Advance_directive

    Description of: Advance_directive

    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.

    Attribute definitions for: Advance_directive

    assessment_dttm

    The date and time the advance directive was identified.

    Rationale: To replace attribute previously inherited from Patient_clinical_item.

    competence_ind

    An indication as to whether the patient was mentally competent when completing the advance directive.

    directive_cd

    A code depicting the nature of the advance directive.

    disclosure_level_cd

    The level of disclosure allowed for this advance directive.

    employment_related_ind

    An indication that the advance directive is employment related.

    To replace attribute previously inherited from Patient_clinical_item.

    life_quality_desc

    A free for text describing quality of life preference of the patient to be used in making intervention decisions.

    mortuary_preference_nm

    The name of the patient's preferred mortuary.

    notarization_dt

    The date the advance directive was notarized.

    Class: Allergy

    Description of: Allergy

    Class steward is Orders/Observation
    Interested committees Patient Administration
    An abnormal reaction of a patient to an allergen.

    Rationale: Generalize usage

    Attribute definitions for: Allergy

    allergen_id

    An identifier of the allergen which causes the allergic reaction.

    |AL1^1^00203^Set ID - AL1| |AL1^3^00205^Allergy Code/Mnemonic/ Description|

    allergy_cd

    An identification code for the patient condition.

    |AL1^3^00205^Allergy Code/Mnemonic/ Description|

    allergy_reaction_cd

    A code specifying an allergic reaction.

    |AL1^5^00207^Allergy Reaction|

    allergy_reaction_description_txt

    Free form textual description of a patient medical condition.

    |AL1^5^00207^Allergy Reaction|

    allergy_severity_cd

    A code indicating the general severity of the patient condition (e.g., severe, moderate, mild, . . .).

    |AL1^4^00206^Allergy Severity|

    allergy_type_cd

    A code indicating the general allergy category (e.g., drug, food, pollen, . . .).

    |AL1^2^00204^Allergy Type|

    assessment_dttm

    The date and time the allergy was identifier.

    Rationale: To replace attribute inherited from Patient_clinical_item.

    employment_related_ind

    n indication that the allergy is employment related.

    Rationale: To replace attribute previously inherited from Patient_clinical_item.

    Class: Appointment

    Description of: Appointment

    Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
    Interested committees Patient Administration
    A planned patient encounter set for a specific time and place.

    Attribute definitions for: Appointment

    appointment_disposition_cd

    A code depicting the disposition of the appointment (e.g., pending, canceled, rescheduled, . . .).

    appointment_duration_qty

    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|

    appointment_reason_cd

    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|

    appointment_request_reason_cd

    A code depicting the reason the appointment is being requested.

    appointment_timing_tq

    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|

    appointment_type_cd

    Code for the type of appointment

    Rationale: Currently in 2.3

    OpenIssue:

    |ARQ^8^00867^Appointment Type| |SCH^8^00867^Appointment Type|

    cancellation_dttm

    The date and time the appointment was canceled.

    cancellation_reason_cd

    A code depicting why the appointment was canceled.

    estimated_duration_amt

    The amount of time the scheduled encounter is expected to last.

    event_reason_code

    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|

    expected_end_dttm

    The expected end date and time of the patient encounter

    expected_service_desc

    Text providing the service(s) expected to be provided in the scheduled encounter.

    expected_start_dttm

    The expected date and time for the start of a patient encounter.

    id

    A unique identifier assigned to an appointment.

    occurence_id

    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|

    overbook_ind

    An indication as to whether the appointment is an overbook.

    scheduling_begin_dttm

    The data and time the scheduling of the appointment began.

    scheduling_completed_dttm

    The date and time the scheduling of the appointment was completed.

    scheduling_status_cd

    A code depicting the status of scheduling the appointment.

    status_cd

    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|

    urgency_cd

    A code depicting the urgency to be seen by a healthcare provider.

    visit_type_cd

    A code used to classify a visit.

    wait_list_priority_nbr

    The priority assigned to an appointment request placed on a wait list.

    Connection definitions for: Appointment

    reserves (0,n) :: Resource_slot :: is_reserved_by (0,n)

    Links a schedule to its contents.

    are_booked_in (1,n) :: Schedule :: contains (0,n)

    schedules (1,n) :: Patient_encounter :: is_scheduled_by (0,n)

    involves (0,n) :: Appointment_contact_person :: participates_in (1,1)

    Class: Appointment_contact_person

    Description of: Appointment_contact_person

    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.

    Attribute definitions for: Appointment_contact_person

    role_cd

    Role that a contact person plays relative to an appointment request

    Rationale: Currently in 2.3 as itemized person information for each role

    OpenIssue:

    Connection definitions for: Appointment_contact_person

    involves (1,1) :: Contact_person :: participates_in (0,n)

    participates_in (1,1) :: Appointment :: involves (0,n)

    Class: Appointment_request

    Description of: Appointment_request

    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:

    Attribute definitions for: Appointment_request

    appointment_rqst_reason_cd

    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|

    appointment_rqst_type_cd

    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|

    equip_selection_criteria_pv

    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|

    id

    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|

    location_selection_criteria_pv

    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|

    occurence_id

    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|

    priority_cd

    The urgency of the request.

    Rationale: Currently in 2.3

    OpenIssue:

    |ARQ^12^00871^Priority|

    repeating_interval_duration_qty

    How long the appointment repetitions should continue, once they have begun.

    Rationale: Currently in 2.3

    OpenIssue:

    |ARQ^14^00873^Repeating Interval Duration|

    requested_ri

    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|

    rqst_event_reason_cd

    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|

    rqsted_duration_qty

    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|

    start_dt

    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|

    time_selection_criteria_pv

    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|

    Connection definitions for: Appointment_request

    requests (0,n) :: Service_request :: is_requested_by (1,1)

    requests (0,n) :: Resource_request :: is_requested_by (1,1)

    Class: Assessment

    Description of: Assessment

    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.

    Class: Authentication

    Description of: Authentication

    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:

    Attribute definitions for: Authentication

    authentication_dt

    This records the date that the contents of the healthcare document were verified by the authenticator.

    Rationale:

    OpenIssue:

    type_cd

    Code indicating the type of authentication that was carried out for the document

    Rationale:

    OpenIssue:

    Connection definitions for: Authentication

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

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

    Class: Bad_debt_billing_account

    Description of: Bad_debt_billing_account

    Class steward is Patient Administration
    A billing account that has been turned over for bad debt collection.

    Attribute definitions for: Bad_debt_billing_account

    bad_debt_recovery_amt

    The amount recovered on a bad debt patient account.

    |PV1^33^00163^Bad Debt Recovery Amount|

    bad_debt_transfer_amt

    The amount of the patient billing account that was turned over to bad debt for collection.

    |PV1^32^00162^Bad Debt Transfer Amount|

    transfer_to_bad_debt_dt

    The date the patient billing account was transferred to bad debt status.

    |PV1^30^00160^Transfer to Bad Debt Date|

    transfer_to_bad_debt_reason_cd

    A code depicting the reason the patient billing account was transferred to bad debts.

    |PV1^29^00159^Transfer to Bad Debt Code|

    Connection definitions for: Bad_debt_billing_account

    is_assigned_to (1,1) :: Bad_debt_collection_agency :: is_assigned (0,n)

    Class: Bad_debt_collection_agency

    Description of: Bad_debt_collection_agency

    Class steward is Patient Administration
    A role assumed by an organization stakeholder. This role is assigned one or more bad debt billing account.

    Connection definitions for: Bad_debt_collection_agency

    is_a_role_of (1,1) :: Organization :: takes_on_role_of (0,1)

    is_assigned (0,n) :: Bad_debt_billing_account :: is_assigned_to (1,1)

    Class: Billing_information_item

    Description of: Billing_information_item

    Class steward is Patient Administration
    Billing account information particular to the national uniform billing form.

    Attribute definitions for: Billing_information_item

    condition_cd

    A code depicting a condition.

    |UB1^7^00536^Condition Code (35-39)| |UB1^12^00541^Spec Program Indicator (44) | |UB2^3^00555^Condition Code (24-30)|

    occurrence_cd

    A code depicting a event.

    |UB1^16^00545^Occurrence (28-32)| |UB2^7^00559^Occurrence Code & Date (32-35)|

    occurrence_dt

    The date of the event depicted in occurrence code.

    |UB2^7^00559^Occurrence Code & Date (32-35)|

    occurrence_span_cd

    A code depicting an event which occurs over a span of time.

    |UB1^13^00542^PSRO/UR Approval Indicator (87) | |UB1^17^00546^Occurrence Span (33) | |UB2^8^00560^Occurrence Span Code/Dates (36)|

    occurrence_span_from_dt

    The from date of the event depicted in occurrence span code.

    |UB1^14^00543^PSRO/UR Approved Stay-Fm (88)| |UB1^18^00547^Occur Span Start Date(33) | |UB2^8^00560^Occurrence Span Code/Dates (36)|

    occurrence_span_thru_dt

    The end date of the event depicted in occurrence span code.

    |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)|

    quantity_amt

    A quantitative value on a bill. The value is qualified by quantity type code.

    |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|

    quantity_type_cd

    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, . . .).

    value_amt

    A value amount qualified by value code.

    |UB1^10^00539^Value Amount & Code (46-49)| |UB2^6^00558^Value Amount & Code|

    value_cd

    A code qualifying the billing information value amount.

    |UB1^10^00539^Value Amount & Code (46-49)| |UB2^6^00558^Value Amount & Code|

    Connection definitions for: Billing_information_item

    pertains_to (1,1) :: Patient_billing_account :: has (0,n)

    Class: Care_event

    Description of: Care_event

    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.

    Class: Certification_second_opinion

    Description of: Certification_second_opinion

    Class steward is Patient Administration
    An alternate medical opinion rendered for an insurance certification.

    Attribute definitions for: Certification_second_opinion

    effective_dt

    The date that the second opinion was obtained.

    |IN3^22^00523^Second Opinion Date|

    status_cd

    A code that depicts the status of the second opinion.

    |IN3^23^00524^Second Opinion Status | |IN3^24^00525^Second Opinion Documentation Received|

    Connection definitions for: Certification_second_opinion

    is_provided_by (1,1) :: Individual_healthcare_practitioner :: provides (0,n)

    provides_opinion_on (1,1) :: Insurance_certification :: includes (0,n)

    Class: Champus_coverage

    Description of: Champus_coverage

    Class steward is Patient Administration
    A type of insurance coverage provided to military veterans and federal workers.

    Attribute definitions for: Champus_coverage

    handicapped_program_cd

    A code depicting the handicapped program in which the patient is enrolled.

    |IN2^65^00805^Military Handicapped Program |

    non_avail_cert_on_file_ind

    A indication as to whether the champus non-avail certification is on file.

    |IN2^18^00489^Champus Non-Avail Cert on File|

    retirement_dt

    The date of retirement for the person covered by Champus.

    |IN2^17^00488^Champus Retire Date|

    station_id

    The identifier of the Champus station.

    |IN2^13^00484^Champus Station|

    Class: Clinical_document_header

    Description of: Clinical_document_header

    Class steward is Information Management (Medical Records)
    Documentation of a health related factor concerning a patient. See the class Document Header in the MDR 2300 model.

    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_code

    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.

    Connection 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)

    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)

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

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

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

    Class: Clinical_observation

    Description of: Clinical_observation

    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.

    Attribute definitions for: Clinical_observation

    abnormal_result_ind

    An indication that the observation results are abnormal.

    clinically_relevant_begin_dttm

    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|

    clinically_relevant_end_dttm

    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|

    last_observed_normal_values_dttm

    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|

    nature_of_abnormal_testing_cd

    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|

    observation_method_cd

    A code indicating the method employed in conducting the observation.

    observation_status_cd

    The status of the clinical result of the observation.

    |OBR^25^00258^Result Status| |OBX^11^00579^Observ Result Status|

    observation_status_dttm

    The effective date and time of the clinical result.

    observation_sub_id

    A sub-group identifier for the observation used to group related observations.

    |OBX^13^00581^User Defined Access Checks|

    observation_value_txt

    Observation value.

    |OBX^5^00573^Observation Value|

    probability_number

    The degree of certainty in the clinical observation expressed as a percentage.

    Rationale: closer to language used in V2.3

    |OBX^9^00577^Probability|

    references_range_text

    )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|

    universal_service_identifier_suffix_txt

    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|

    user_defined_access_check_txt

    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|

    value_type_cd

    A qualifier of the observation value.

    |OBX^2^00570^Value Type| |OM3^7^00570^Value Type|

    value_units_code

    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: Collected_specimen_sample

    Description of: Collected_specimen_sample

    Class steward is Orders/Observation
    A sample of a substance or material for examination or study (a urine specimen; a tissue specimen).

    Attribute definitions for: Collected_specimen_sample

    body_site_cd

    The anatomical source for the collected item.

    Rationale: more specific to related component of V2.3 field

    |OBR^15^00249^Specimen Source|

    collection_body_site_modifier_cd

    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|

    collection_end_dttm

    The date and time the analyzed object collection ended.

    |OBR^8^00242^Observation End Date/Time|

    collection_method_modifier_cd

    coded modifier for the method of collection of a specimen.

    Rationale: required by components of V2.3 field

    OpenIssue:

    |OBR^15^00249^Specimen Source|

    collection_scheduled_dttm

    The date and time the analyzed object is scheduled to be collected.

    collection_start_dttm

    The date and time the analyzed object collection started.

    |OBR^7^00241^Observation Date/Time|

    collection_volume_amt

    The amount of specimen collected.

    |OBR^9^00243^Collection Volume|

    condition_cd

    A description of the condition of the collected specimen.

    Rationale: V2.3 field is CE datatype

    |OBR^39^01030^Collector’s Comment|

    handling_cd

    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, . . .).

    id

    Unique identifier of the analyzed object.

    method_of_collection_desc

    A description of the method used to collect the analyzed object.

    number_of_sample_containers_qty

    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|

    specimen_additive_txt

    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|

    specimen_danger_cd

    A code depicting dangers associated with the analyzed object.

    specimen_source_cd

    A code indicating the source of the analyzed object.

    |OBR^15^00249^Specimen Source|

    transport_logistics_cd

    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|

    Connection definitions for: Collected_specimen_sample

    is_sourced_from (0,1) :: Patient :: is_source_for (0,n)

    is_collected_during (0,1) :: Procedure :: collects (0,n)

    Rationale: Add Procedure as possible source of specimen.

    is_collected_by (1,1) :: Stakeholder :: collects (0,n)

    is_target_of (0,n) :: Target_participation :: has_as_target (0,1)

    Rationale: Replaces association Collected_specimen_sample is_used_during Service_event.

    Class: Consent

    Description of: Consent

    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.

    Class: Contact_person

    Description of: Contact_person

    Class steward is Patient Administration

    Attribute definitions for: Contact_person

    contact_reason_cd

    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|

    Connection definitions for: Contact_person

    is_a_contact_for (0,1) :: Guarantor :: has_as_a_contact (0,n)

    is_a_contact_for (0,1) :: Insurer :: has_as_a_contact (0,n)

    is_a_contact_for (0,1) :: Patient :: has_as_a_contact (0,n)

    is_a_role_of (1,1) :: Person :: takes_on_role_of (0,1)

    participates_in (0,n) :: Appointment_contact_person :: involves (1,1)

    is_a_contact_for (0,1) :: Health_benefit_plan_purchaser :: has_as_a_contact (0,n)

    is_a_contact_for (0,1) :: Employer :: has_as_a_contact (0,n)

    Class: Diagnostic_related_group

    Description of: Diagnostic_related_group

    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>

    Attribute definitions for: Diagnostic_related_group

    base_rate_amt

    <see FIN2301:DRG_Master_File>

    capital_reimbursement_amt

    <see FIN2301:DRG_Master_File>

    cost_weight_amt

    <see FIN2301:DRG_Master_File>

    id

    A unique identifier assigned to the diagnostic related group.

    |DG1^8^00382^Diagnostic Related Group| |DRG^1^00382^Diagnostic Related Group|

    major_diagnostic_category_cd

    <see FIN2301:DRG_Master_File>

    operating_reimbursement_amt

    <see FIN2301:DRG_Master_File>

    reimbursement_amt

    <see FIN2301:DRG_Master_File>

    standard_day_qty

    <see FIN2301:DRG_Master_File; Standard_Day_Stay>

    standard_total_charge_amt

    <see FIN2301:DRG_Master_File>

    trim_high_day_qty

    <see FIN2301:DRG_Master_File>

    trim_low_day_qty

    <see FIN2301:DRG_Master_File>

    Connection definitions for: Diagnostic_related_group

    is_assigned_as (0,n) :: Encounter_drg :: is_an_assignment_of (1,1)

    Class: Dietary_intent_or_order

    Description of: Dietary_intent_or_order

    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

    Attribute definitions for: Dietary_intent_or_order

    diet_type_cd

    A code identifying a special diet type for a patient.

    |ODS^1^00269^Type| |PV1^38^00168^Diet Type|

    dietary_instruction_desc

    Instructive description of the dietary order.

    |ODS^4^00272^Text Instruction| |ODT^3^00272^Text Instruction|

    dietary_tray_type_cd

    A code for the type of dietary tray.

    |ODT^1^00273^Tray Type|

    service_period_cd

    A code identifying the service period for a diet order.

    |ODS^2^00270^Service Period| |ODT^2^00270^Service Period|

    service_type_cd

    An identifier of the dietary plan.

    Rationale: related V2.3 field is CE datatype. this is not an identifier.

    OpenIssue:

    |ODS^3^00271^Diet, Supplement, or Preference Code|

    Class: Disability

    Description of: Disability

    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

    Attribute definitions for: Disability

    effective_dt

    The date that this administrative disability became effective.

    Rationale: DB1-5

    OpenIssue:

    |DB1^5^01287^Disability Start Date|

    return_to_work_auth_dt

    The date the person was authorized to return to work.

    Rationale: DB1-7

    OpenIssue:

    |DB1^7^01289^Disability Return to Work Date|

    termination_dt

    The date that this disability ended.

    Rationale: DB1-6

    OpenIssue:

    |DB1^6^01288^Disability End Date|

    unable_to_work_effective_dt

    The date the person was unable to work due to this disability.

    Rationale: DB1-8

    OpenIssue:

    |DB1^8^01290^Disability Unable to Work Date|

    Connection definitions for: Disability

    pertains_to (1,1) :: Patient :: has (0,n)

    Rationale: 2.3 abstract message definition

    OpenIssue:

    Class: Document_recipient

    Description of: Document_recipient

    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:

    Connection definitions for: Document_recipient

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

    is_a (1,1) :: Stakeholder :: may_act_as_a (0,1)

    Class: Durable_medical_equipment

    Description of: Durable_medical_equipment

    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.

    Attribute definitions for: Durable_medical_equipment

    id

    A unique identifier for a specific piece of equipment.

    Rationale: Currently in 2.3

    OpenIssue:

    |AIG^3^00897^Resource ID|

    slot_size_increment_qty

    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?

    type_cd

    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|

    Connection definitions for: Durable_medical_equipment

    belongs_to (0,n) :: Durable_medical_equipment_group :: contains (1,n)

    is_requested_by (0,n) :: Durable_medical_equipment_request :: requests (1,1)

    is_scheduled_by (0,n) :: Durable_medical_equipment_slot :: is_a_scheduleable_unit_for (1,1)

    Rationale:

    OpenIssue: It would be nice to have a description and rationale for this connection.

    Class: Durable_medical_equipment_group

    Description of: Durable_medical_equipment_group

    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:

    Attribute definitions for: Durable_medical_equipment_group

    id

    Unique identifier for the group

    Rationale: Currently in 2.3

    OpenIssue:

    |AIG^5^00899^Resource Group| |AIP^5^00899^Resource Group|

    Connection definitions for: Durable_medical_equipment_group

    contains (1,n) :: Durable_medical_equipment :: belongs_to (0,n)

    is_requested_by (0,n) :: Durable_medical_equipment_request :: may_request (0,1)

    Class: Durable_medical_equipment_request

    Description of: Durable_medical_equipment_request

    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:

    Attribute definitions for: Durable_medical_equipment_request

    quantity

    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|

    type_cd

    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|

    Connection definitions for: Durable_medical_equipment_request

    may_request (0,1) :: Durable_medical_equipment_group :: is_requested_by (0,n)

    requests (1,1) :: Durable_medical_equipment :: is_requested_by (0,n)

    Class: Durable_medical_equipment_slot

    Description of: Durable_medical_equipment_slot

    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:

    Connection definitions for: Durable_medical_equipment_slot

    is_a_scheduleable_unit_for (1,1) :: Durable_medical_equipment :: is_scheduled_by (0,n)

    Rationale:

    OpenIssue: It would be nice to have a description and rationale for this connection.

    Class: Employee

    Description of: Employee

    Class steward is Patient Administration
    An employed person.

    Connection definitions for: Employee

    is_employee_in (0,n) :: Person_employment :: has_as_employee (1,1)

    is_a_role_of (1,1) :: Person :: takes_on_role_of (0,1)

    Class: Employer

    Description of: Employer

    Class steward is Patient Administration
    A person or organization which employs persons.

    Attribute definitions for: Employer

    effective_dt

    The date the organization assumes the role of employer.

    termination_dt

    The date the organization's role as employer is terminated.

    Connection definitions for: Employer

    has_as_a_contact (0,n) :: Contact_person :: is_a_contact_for (0,1)

    is_a_role_of (1,1) :: Stakeholder :: takes_on_role_of (0,1)

    is_employer_of (0,n) :: Person_employment :: has_as_employer (1,1)

    Class: Encounter_drg

    Description of: Encounter_drg

    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.

    Attribute definitions for: Encounter_drg

    approval_ind

    An indication that the DRG assignment has been approved by a reviewing entity.

    |DG1^9^00383^DRG Approval Indicator| |DRG^3^00383^DRG Approval Indicator|

    assigned_dttm

    The date and time the DRG was assigned to the encounter.

    |DRG^2^00769^DRG Assigned Date/Time |

    confidential_ind

    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|

    cost_outlier_amt

    The amount of the encounter cost that is beyond the standard cost amount for the assigned DRG.

    |DG1^13^00387^Outlier Cost| |DRG^7^00387^Outlier Cost|

    desc

    A description providing additional information about the assignment of the DRG to the encounter.

    grouper_review_cd

    A code indicating that the grouper results have been reviewed and approved.

    |DG1^10^00384^DRG Grouper Review Code| |DRG^4^00384^DRG Grouper Review Code|

    grouper_version_id

    The version and type of the grouper used to derive the DRG.

    outlier_days_qty

    The number of days beyond the standard day count for the assigned DRG.

    |DG1^12^00386^Outlier Days| |DRG^6^00386^Outlier Days|

    outlier_reimbursement_amt

    The portion of the total reimbursement amount designated for reimbursement of outlier days or costs.

    |DRG^9^00771^Outlier Reimbursement|

    outlier_type_cd

    A code depicting the type of outlier (day, cost) associated with the encounter DRG.

    Connection definitions for: Encounter_drg

    is_assigned_by (1,1) :: Organization :: assigns (0,n)

    is_assigned_to (1,1) :: Inpatient_encounter :: is_assigned (0,n)

    is_an_assignment_of (1,1) :: Diagnostic_related_group :: is_assigned_as (0,n)

    Class: Encounter_practitioner

    Description of: Encounter_practitioner

    Class steward is Patient Administration
    An association between a Healthcare practitioner and a patient encounter.

    Attribute definitions for: Encounter_practitioner

    participation_type_cd

    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).

    Connection definitions for: Encounter_practitioner

    is_associated_with (1,1) :: Patient_encounter :: has_as_participant (1,n)

    is_participant_for (1,1) :: Individual_healthcare_practitioner :: participates_as (0,n)

    Class: Episode

    Description of: Episode

    Class steward is Patient Administration
    A collection or a series of Healthcare encounters for a patient.

    Attribute definitions for: Episode

    desc

    Episode of care descriptive text.

    episode_type_cd

    A code indicating the type of episode. The type code is dependent upon the reason for collection of patient encounters.

    id

    A unique identifier assigned to the episode of care.

    list_closed_ind

    An indication that the list of encounters associated with the episode is a closed list.

    outcome_txt

    Text describing the outcome of the episode of care.

    recurring_service_ind

    An indication that the episode represents a recurring patient service.

    Connection definitions for: Episode

    specfies (0,n) :: Problem :: specified_in (0,1)

    Whole-part definitions for: Episode

    has_parts (1,n) :: Patient_encounter :: is_part_of (1,1)

    Class: Financial_transaction

    Description of: Financial_transaction

    Class steward is Patient Administration
    A charge, credit, or adjustment to charges in a patient's billing account.

    Attribute definitions for: Financial_transaction

    alternate_desc

    An alternate description of the transaction.

    |FT1^9^00363^Transaction Description - Alt|

    desc

    Explanatory text concerning a financial transaction.

    |FT1^8^00362^Transaction Description|

    extended_amt

    The transaction amount derived from multiplying the unit amount by the number of units.

    |FT1^11^00365^Transaction Amount - Extended|

    fee_schedule_cd

    A code depicting the fee schedule used for this financial transaction.

    |FT1^17^00370^Fee Schedule|

    insurance_amt

    The amount of the financial transaction that is applicable to the associated Healthcare benefit plan.

    |FT1^15^00369^Insurance Amount|

    posting_dt

    The posting date of the financial transaction.

    |FT1^5^00359^Transaction Posting Date|

    qty

    transaction quantity.

    |FT1^10^00364^Transaction Quantity|

    transaction_batch_id

    A unique identifier assigned to the batch in which this transaction belongs.

    |FT1^3^00357^Transaction Batch ID|

    transaction_cd

    A code depicting the financial action covered in the transaction.

    |FT1^7^00361^Transaction Code|

    transaction_dt

    The date of the transaction.

    |FT1^4^00358^Transaction Date|

    transaction_id

    A identifier assigned to the transaction for control purposes.

    |FT1^2^00356^Transaction ID| |UB2^12^00564^Document Control Number|

    transaction_type_cd

    A code depicting the transaction type (e.g., credit, charge, payment, adjustment, ...).

    |FT1^6^00360^Transaction Type|

    unit_amt

    The amount associated with one transaction unit.

    |FT1^12^00366^Transaction Amount - Unit|

    unit_cost_amt

    The unit price of transaction. The cost of a single item.

    |FT1^22^00374^Unit Cost|

    Connection definitions for: Financial_transaction

    is_associated_with (0,1) :: Healthcare_benefit_plan :: is_associated_with (0,n)

    is_associated_with (1,1) :: Patient_billing_account :: has (0,n)

    is_entered_by (1,1) :: Person :: enters (0,n)

    pertains_to (1,1) :: Service_event :: is_associated_with (0,n)

    is_categorized_by (0,1) :: Organization :: categorizes (0,n)

    Class: Goal

    Description of: Goal

    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.

    Attribute definitions for: Goal

    action_cd

    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|

    action_dttm

    Event date time

    Rationale: Conformance with v 2.3

    OpenIssue:

    |GOL^2^00817^Action Date/Time| |PRB^2^00817^Action Date/Time|

    classification_cd

    A code used to categorize patient pathway goals.

    current_review_status_cd

    A code depicting the review status of the patient pathway goal.

    current_review_status_dttm

    The date/time of the most recent review of the patient pathway goal.

    episode_of_care_id

    Episode of Care

    Rationale: Conformance with v 2.3

    OpenIssue:

    established_dttm

    The date/time the patient goal is initially created.

    evaluation_cd

    A code depicting the progress towards achievement of the goal (e.g., achieved, ahead of schedule, delayed, failed to achieve, . . .).

    evaluation_comment_txt

    Comment text associated with the goal evaluation.

    expected_achievement_dttm

    Date goal is expected to be achieved

    Rationale: Conformance with v 2.3

    OpenIssue:

    goal_cd

    Standard code or name for the goal.

    Rationale: Vocabulary reference

    goal_list_priority_num

    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|

    life_cycle_dttm

    The effective date/time of the most recently assigned goal life cycle.

    life_cycle_status_cd

    A code indicating the state of the goal (e.g., active, canceled, inactive, suspended, . . .).

    management_discipline_cd

    A code indicating the caregiver disciplines responsible for managing a patient pathway goal.

    next_review_dttm

    The date/time of the next scheduled goal review.

    previous_review_dttm

    The second most recent date/time the goal was reviewed.

    review_interval_cd

    A code indication the review interval for the patient pathway goal.

    target_txt

    Text description of who/what the goal target is.

    Rationale: Conformance with v 2.3

    OpenIssue:

    target_type_cd

    A code used to identify the individual or group for whom the goal has been established for the benefit of a particular patient (e.g., family group, family member, patient, . . .).

    Class: Guarantor

    Description of: Guarantor

    Class steward is Patient Administration
    The person or organization assuming financial responsibility for some or all of the charges in a patient billing account.

    Attribute definitions for: Guarantor

    financial_class_cd

    A code depicting the classification of the financial status of the guarantor.

    household_annual_income_amt

    The combined annual income of all members of the guarantor's household.

    |GT1^27^00778^Guarantor Household Annual Income|

    household_size_qty

    The number of people living at the guarantor's primary residence.

    |GT1^28^00779^Guarantor Household Size|

    Connection definitions for: Guarantor

    guarantees_payment_under (1,n) :: Guarantor_contract :: has_payment_guaranteed_by (1,1)

    is_a_role_of (1,1) :: Stakeholder :: takes_on_role_of (0,1)

    has_as_a_contact (0,n) :: Contact_person :: is_a_contact_for (0,1)

    Class: Guarantor_contract

    Description of: Guarantor_contract

    Class steward is Patient Administration
    A contract held by a stakeholder which specifies the financial responsibility of the stakeholder for a patient billing account.

    Attribute definitions for: Guarantor_contract

    billing_hold_ind

    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|

    billing_media_cd

    A code depicting the allowable mediums for billing under this guarantor contract.

    |PV2^32^00733^Billing Media Code|

    charge_adjustment_cd

    A code depicting which adjustments should be made to this guarantor's charges.

    |GT1^26^00777^Guarantor Charge Adjustment Code|

    contract_duration_cd

    A code specifying the duration of the contract.

    |PV1^27^00157^Contract Period|

    contract_type_cd

    Code identifying the type of contract entered into by the guarantor for the purpose of settling outstanding account balances.

    |GT1^10^00414^Guarantor Type| |PV1^24^00154^Contract Code|

    effective_dt

    The date the guarantor contract becomes effective.

    |GT1^13^00417^Guarantor Date - Begin| |PV1^25^00155^Contract Effective Date|

    interest_rate_amt

    The rate of interest for this guarantor contract.

    |PV1^28^00158^Interest Code|

    periodic_payment_amt

    Amount to be paid by the guarantor each period.

    |PV1^26^00156^Contract Amount|

    priority_ranking_cd

    A code indicating the relative priority of this guarantor contract for a given patient billing account.

    |GT1^15^00419^Guarantor Priority| |GT1^29^00780^Guarantor Employer ID Number|

    separate_bill_ind

    An indication as to whether the baby in a delivery patient stay should be billed separately.

    |PD1^9^00761^Separate Bill|

    termination_dt

    The date the guarantor contract is no longer in effect.

    |GT1^14^00418^Guarantor Date - End|

    Connection definitions for: Guarantor_contract

    has_coverage_affirmed_by (0,n) :: Insurance_certification :: affirms_insurance_coverage_for (1,1)

    provides_payment_guarantee_for (0,n) :: Patient_billing_account :: has_payment_guaranteed_by (0,n)

    has_payment_guaranteed_by (1,1) :: Guarantor :: guarantees_payment_under (1,n)

    Class: Health_benefit_plan_purchaser

    Description of: Health_benefit_plan_purchaser

    Class steward is Patient Administration
    A person or organization which is a purchaser of a health benefit plan.

    Connection definitions for: Health_benefit_plan_purchaser

    is_a_role_of (1,1) :: Stakeholder :: takes_on_role_of (0,1)

    is_the_purchaser_of (0,n) :: Healthcare_benefit_plan :: has_as_purchaser (1,1)

    has_as_a_contact (0,n) :: Contact_person :: is_a_contact_for (0,1)

    Class: Health_chart

    Description of: Health_chart

    Class steward is Information Management (Medical Records)
    A record of health related events, facts, and related data for a particular patient.

    Attribute definitions for: Health_chart

    health_chart_id

    An identifier designated for the health chart.

    health_chart_type_cd

    A classification code for the health chart (e.g., inpatient, outpatient, mental health, . . .).

    status_cd

    The current status of the health chart.

    Connection definitions for: Health_chart

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

    has_an_assessment_of (0,n) :: Health_chart_deficiency :: is_assessed_against (1,1)

    is_housed_at (1,1) :: Patient_service_location :: houses (0,n)

    belongs_to (1,1) :: Patient :: has (0,n)

    Class: Health_chart_deficiency

    Description of: Health_chart_deficiency

    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>

    Attribute definitions for: Health_chart_deficiency

    assessment_dt

    The date the chart deficiency was determined.

    desc

    A description of the health chart discrepancy.

    level_cd

    A code depicting the level of discrepancy found in the health chart.

    type_cd

    A code identifying the type of deficiency identified.

    Connection definitions for: Health_chart_deficiency

    is_assessed_against (1,1) :: Health_chart :: has_an_assessment_of (0,n)

    Class: Healthcare_benefit_plan

    Description of: Healthcare_benefit_plan

    Class steward is Patient Administration
    A collection of health benefits.

    Attribute definitions for: Healthcare_benefit_plan

    agreement_type_cd

    A code serving as an additional refinement of an insurance plan. (e.g., standard, unified, maternity, . . .).

    |IN1^31^00456^Type of Agreement Code|

    assignment_of_benefits_ind

    An indication as to whether the insured agreed to assign the insurance benefits to the healthcare provider.

    |IN1^20^00445^Assignment of Benefits|

    baby_coverage_ind

    An indication of the existence of baby coverage under the insurance plan.

    |IN2^19^00490^Baby Coverage|

    benefit_desc

    A description of the healthcare benefit.

    benefit_plan_id

    An identifier for the healthcare coverage benefit plan.

    |IN1^46^00471^Prior Insurance Plan ID|

    benefit_plan_nm

    The name of the benefit plan.

    benefit_plan_type_cd

    A code classifying the benefit plan type (e.g., commercial, Medicare, Medicaid, . . .).

    |DRG^8^00770^DRG Payor| |IN1^15^00440^Plan Type|

    benefits_coordination_ind

    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|

    blood_deductible_amt

    The deductible amount for blood.

    |IN2^21^00492^Blood Deductible|

    cob_priority_nbr

    The priority sequence for an insurance plan that works in conjunction with other insurance.

    |IN1^22^00447^Coord of Ben. Priority|

    combine_baby_bill_ind

    An indication as to whether charges for a baby should be combined with charges for the mother.

    |IN2^20^00491^Combine Baby Bill|

    copay_limit_ind

    An indication as to whether the patient has reached the copay limit.

    |IN2^67^00807^Copay Limit Flag|

    coverage_type_cd

    A code identifying the type of insurance coverage, or what type of services are covered for the purposes of a billing system.

    daily_deductible_amt

    The amount of the daily deductible for this insurance plan.

    |IN2^30^00501^Daily Deductible|

    effective_dt

    The date the healthcare coverage first becomes effective.

    |IN1^12^00437^Plan Effective Date|

    eligibility_source_cd

    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|

    expiration_dt

    The last date of service that the insurance will cover or be responsible for.

    |IN1^13^00438^Plan Expiration Date|

    group_benefit_ind

    A indication as to whether the healthcare coverage is a group contract.

    mail_claim_party_cd

    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|

    non_covered_insurance_cd

    A code depicting the reason why a service is not covered.

    |IN2^24^00495^Non-Covered Insurance Code|

    plan_id

    An identifier of an healthcare benefit plan.

    |IN1^35^00460^Company Plan Code|

    policy_amount_class_cd

    The code classifying the amount (e.g. AT-Amount, PC-Percentage, LM-Limit)

    Rationale: IN2-29

    OpenIssue:

    |IN2^29^00500^Policy Type/Amount|

    policy_amt

    The benefit limit amount or percentage.

    Rationale: IN2-29

    OpenIssue:

    |IN2^29^00500^Policy Type/Amount|

    policy_category_cd

    The policy category code (e.g., ANC-ancillary, MMD-major medical)

    Rationale: IN2-29

    OpenIssue:

    |IN2^29^00500^Policy Type/Amount|

    policy_deductible_amt

    The deductible amount specified by the insurance plan.

    |IN1^37^00462^Policy Deductible|

    policy_id

    The identifier for the healthcare coverage policy.

    |IN1^36^00461^Policy Number|

    policy_limit_day_qty

    The maximum number of days that the insurance policy will cover.

    |IN1^39^00464^Policy Limit - Days|

    policy_scope_cd

    A code depicting the extent of the coverage for a participating member (e.g., single, family, . . .).

    |IN2^59^00799^Policy Scope |

    policy_source_cd

    A code indicating how the policy information was obtained.

    |IN2^60^00800^Policy Source | |SCH^22^00800^Policy Source |

    release_information_cd

    A code describing what information, if any, a provider can release about a patient.

    |IN1^27^00452^Release Information Code|

    report_of_eligibility_dt

    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|

    report_of_eligibility_ind

    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|

    room_coverage_type_amount_cd

    A rate for a given room type.

    |IN2^28^00499^Room Coverage Type/Amount|

    status_cd

    A code depicting the status of the healthcare coverage.

    |IN2^16^00487^Champus Status|

    termination_dt

    The date the healthcare coverage is no longer in effect.

    Connection definitions for: Healthcare_benefit_plan

    governs (0,n) :: Preferred_provider_participation :: is_governed_by (0,1)

    is_validated_by (0,n) :: Insurance_certification :: provides_validation_for (1,1)

    is_associated_with (0,n) :: Financial_transaction :: is_associated_with (0,1)

    is_for (1,1) :: Patient :: has (0,n)

    is_offered_by (1,1) :: Insurer :: offers (0,n)

    has_as_purchaser (1,1) :: Health_benefit_plan_purchaser :: is_the_purchaser_of (0,n)

    Whole-part definitions for: Healthcare_benefit_plan

    has_parts (0,n) :: Healthcare_coverage_benefit :: is_part_of (1,1)

    Class: Healthcare_benefit_service

    Description of: Healthcare_benefit_service

    Class steward is Patient Administration
    A level of coverage for a selected class of Healthcare services.

    Attribute definitions for: Healthcare_benefit_service

    access_protocol_desc

    Description of the access protocol for the benefit service type.

    capitation_ind

    An indication that the benefit service is a capitated service.

    coinsurance_ind

    An indication that coinsurance is applicable for the benefit service.

    coinsurance_pct

    The coinsurance percentage for the benefit service.

    copayment_amt

    The copayment amount for the benefit service.

    deductible_amt

    The benefit service deductible amount.

    lower_coverage_limit_amt

    The lower coverage limit.

    pay_cap_limit_amt

    The payment limit on the benefit service.

    pcp_referral_ind

    An indicator that the benefit service provided by a non primary provider must have a referral from a primary care provider to be covered.

    primary_care_provider_ind

    An indicator that the benefit service must be provided by a primary care provider to be covered.

    review_ind

    A indication that the benefit service will be subject to review prior to payment.

    |IN3^20^00521^Pre-Certification Req/Window|

    upper_coverage_limit_amt

    The upper limit of the benefit coverage.

    Connection definitions for: Healthcare_benefit_service

    provides_coverage_for (1,n) :: Master_service :: is_covered_by (0,n)

    Whole-part definitions for: Healthcare_benefit_service

    is_part_of (1,1) :: Healthcare_coverage_benefit :: has_parts (0,n)

    Class: Healthcare_coverage_benefit

    Description of: Healthcare_coverage_benefit

    Class steward is Patient Administration
    A defined level of healthcare insurance coverage.

    Attribute definitions for: Healthcare_coverage_benefit

    annual_limit_amt

    The annual limit amount for the Healthcare coverage benefit.

    benefit_desc

    A textual description of the benefit.

    benefit_product_nm

    The name of the benefit product.

    dependent_coverage_ind

    An indication as to whether the benefit includes dependent coverage.

    dependent_coverage_limit_amt

    The limit on the dependent coverage amount.

    effective_dttm

    The date and time the benefit becomes effective.

    lifetime_limit_amt

    The lifetime limit amount for the Healthcare coverage benefit.

    termination_dttm

    The date the benefit is no longer in effect.

    Whole-part definitions for: Healthcare_coverage_benefit

    has_parts (0,n) :: Healthcare_benefit_service :: is_part_of (1,1)

    is_part_of (1,1) :: Healthcare_benefit_plan :: has_parts (0,n)

    Class: Healthcare_document_authenticator

    Description of: Healthcare_document_authenticator

    Class steward is Information Management (Medical Records)

    Rationale: Identity of the authenticator is a key piece of information associated with a document.

    OpenIssue:

    Connection definitions for: Healthcare_document_authenticator

    is_a (1,1) :: Stakeholder :: takes_on_role_of (0,1)

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

    Class: Healthcare_provider_organization

    Description of: Healthcare_provider_organization

    Class steward is Patient Administration

    Connection definitions for: Healthcare_provider_organization

    is_a_role_of (1,1) :: Organization :: takes_on_role_of (0,1)

    provides_patient_services_at (0,n) :: Patient_service_location :: provides_services_on_behalf_of (1,n)

    Class: Healthcare_service_provider

    Description of: Healthcare_service_provider

    Class steward is Patient Administration
    An organization or person responsible for the provision of healthcare services to an individual, or involved in the provision of healthcare related services.

    Attribute definitions for: Healthcare_service_provider

    board_certification_type_cd

    The type of board certification held by the healthcare provider.

    board_certified_ind

    An indication that the healthcare provider is board certified.

    certification_dt

    The date of certification.

    effective_dt

    The date the stakeholder assumes the role of healthcare service provider.

    license_id

    The unique identifier assigned to the healthcare service providers license.

    recertification_dt

    The date recertification is required.

    specialty_cd

    A code depicting the particular subject area or branch of medical science, as practiced by a Healthcare practitioner.

    termination_dt

    The date the stakeholder is no longer in the role of Healthcare service provider.

    Connection definitions for: Healthcare_service_provider

    participates_as (0,n) :: Producer_of_master_service :: has_as_participant (1,1)

    participates_in (0,n) :: Preferred_provider_participation :: has_as_care_provider (1,1)

    Rationale: A person's PCP can be either a practitioner or a provider organization.

    Class: Identifier_issuing_authority

    Description of: Identifier_issuing_authority

    Class steward is Patient Administration
    A role assumed by an organization stakeholder. This role issues identifiers.

    Attribute definitions for: Identifier_issuing_authority

    effective_dt

    The date the organization assumes the role of issuing authority for identifiers.

    termination_dt

    The date the organization is no longer in the role of issuing authority for identifiers.

    Connection definitions for: Identifier_issuing_authority

    is_a_role_of (1,1) :: Organization :: takes_on_role_of (0,1)

    issues (0,n) :: Stakeholder_identifier :: is_issued_by (1,1)

    Class: Individual_healthcare_practitioner

    Description of: Individual_healthcare_practitioner

    Class steward is Patient Administration
    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.

    Attribute definitions for: Individual_healthcare_practitioner

    desc

    Free form text description of the healthcare practitioner.

    fellowship_field_cd

    The fellowship field of a physician.

    graduate_school_nm

    The name of the graduate school attended by the healthcare practitioner.

    graduation_dt

    The date of graduation from graduated school.

    position_cd

    A code indicating the position of a healthcare practitioner in an healthcare organization (e.g., head of department, trainee, hospital consultant, . . .).

    practitioner_type_cd

    A code indicating the type of healthcare professional (e.g., medical doctor, nurse, pharmacist, laboratory worker, . . .).

    primary_care_ind

    An indication that the healthcare practitioner is a primary care provider.

    residency_field_cd

    The physician residency code.

    slot_size_increment_qty

    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?

    Connection definitions for: Individual_healthcare_practitioner

    belongs_to (0,n) :: Individual_healthcare_provider_group :: contains (1,n)

    is_requested_by (0,n) :: Individual_healthcare_provider_request :: requests (1,1)

    is_scheduled_by (0,n) :: Individual_healthcare_provider_slot :: is_a_scheduleable_unit_for (1,1)

    participates_as (0,n) :: Encounter_practitioner :: is_participant_for (1,1)

    provides (0,n) :: Certification_second_opinion :: is_provided_by (1,1)

    is_the_primary_provider_for (0,n) :: Patient :: has_a_primary_provider (0,1)

    is_a_role_of (1,1) :: Person :: takes_on_role_of (0,1)

    Class: Individual_healthcare_provider_group

    Description of: Individual_healthcare_provider_group

    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?

    Attribute definitions for: Individual_healthcare_provider_group

    id

    Unique identifier for the group

    Rationale: Currently in 2.3

    OpenIssue:

    |AIG^5^00899^Resource Group| |AIP^5^00899^Resource Group|

    Connection definitions for: Individual_healthcare_provider_group

    is_requested_by (0,n) :: Individual_healthcare_provider_request :: may_request (0,1)

    contains (1,n) :: Individual_healthcare_practitioner :: belongs_to (0,n)

    Class: Individual_healthcare_provider_request

    Description of: Individual_healthcare_provider_request

    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:

    Attribute definitions for: Individual_healthcare_provider_request

    practitioner_type_cd

    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|

    Connection definitions for: Individual_healthcare_provider_request

    requests (1,1) :: Individual_healthcare_practitioner :: is_requested_by (0,n)

    may_request (0,1) :: Individual_healthcare_provider_group :: is_requested_by (0,n)

    Class: Individual_healthcare_provider_slot

    Description of: Individual_healthcare_provider_slot

    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:

    Connection definitions for: Individual_healthcare_provider_slot

    is_a_scheduleable_unit_for (1,1) :: Individual_healthcare_practitioner :: is_scheduled_by (0,n)

    Class: Inpatient_encounter

    Description of: Inpatient_encounter

    Class steward is Patient Administration
    A patient encounter involving an admission to an inpatient facility.

    Attribute definitions for: Inpatient_encounter

    actual_days_qty

    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|

    estimated_days_qty

    The estimated number of days in an inpatient encounter.

    |PV2^10^00711^Estimated Length of Inpatient Stay|

    Connection definitions for: Inpatient_encounter

    is_terminated_by (0,1) :: Patient_departure :: terminates (1,1)

    is_preceded_by (1,1) :: Patient_admission :: preceded (1,1)

    is_assigned (0,n) :: Encounter_drg :: is_assigned_to (1,1)

    Class: Insurance_certification

    Description of: Insurance_certification

    Class steward is Patient Administration
    An affirmation by an insurance company that it will pay for a specified service.

    Attribute definitions for: Insurance_certification

    appeal_reason_cd

    A code depicting the reason an appeal was made on a non-concur for certification.

    |IN3^17^00518^Appeal Reason|

    certification_day_qty

    A count of the number of days for which this certification is valid.

    |IN3^11^00512^Days|

    effective_dt

    The date that this certification becomes effective.

    |IN3^6^00507^Certification Date/Time| |IN3^9^00510^Certification Begin Date|

    id

    A unique identifier for the certification assigned by the certification agency.

    |IN3^2^00503^Certification Number|

    insurance_verification_dttm

    The data and time the insurance coverage was verified.

    |IN1^29^00454^Verification Date/Time|

    modification_dttm

    The date/time that the certification was modified.

    |IN3^7^00508^Certification Modify Date/Time|

    non_concur_cd

    A code depicting the denied request.

    |IN3^12^00513^Non-Concur Code/Description|

    non_concur_effective_dttm

    The date of the non-concurrence classification.

    |IN3^13^00514^Non-Concur Effective Date/Time|

    penalty_amt

    The dollar amount of the penalty that will be assessed if the precertification is not performed.

    |IN3^5^00506^Penalty|

    termination_dt

    The date the certification ends.

    |IN3^10^00511^Certification End Date|

    Connection definitions for: Insurance_certification

    has_as_a_contact (1,n) :: Insurance_certification_contact :: is_a_contact_for (1,1)

    provides_validation_for (1,1) :: Healthcare_benefit_plan :: is_validated_by (0,n)

    affirms_insurance_coverage_for (1,1) :: Guarantor_contract :: has_coverage_affirmed_by (0,n)

    is_issued_by (1,1) :: Insurer :: issues (0,n)

    includes (0,n) :: Certification_second_opinion :: provides_opinion_on (1,1)

    Class: Insurance_certification_contact

    Description of: Insurance_certification_contact

    Class steward is Patient Administration
    A person or organization which acts as a contact for insurance certifications.

    Attribute definitions for: Insurance_certification_contact

    participation_type_cd

    A code depicting the type of certification contact. (e.g., certification agency, certification operator, approving party, physician reviewer, . . .).

    Connection definitions for: Insurance_certification_contact

    is_a_contact_for (1,1) :: Insurance_certification :: has_as_a_contact (1,n)

    is_a_role_of (1,1) :: Stakeholder :: takes_on_role_of (0,1)

    Class: Insurer

    Description of: Insurer

    Class steward is Patient Administration
    A role assumed by a organization stakeholder underwriting a Healthcare benefit plan.

    Attribute definitions for: Insurer

    effective_dt

    The date the organization assumes the role of insurer.

    termination_dt

    The date the organization is no longer in the role of insurer.

    Connection definitions for: Insurer

    issues (0,n) :: Insurance_certification :: is_issued_by (1,1)

    issues (0,n) :: Preauthorization :: is_issued_by (1,1)

    offers (0,n) :: Healthcare_benefit_plan :: is_offered_by (1,1)

    is_a_role_of (1,1) :: Organization :: takes_on_role_of (0,1)

    has_as_a_contact (0,n) :: Contact_person :: is_a_contact_for (0,1)

    Class: Location_encounter_role

    Description of: Location_encounter_role

    Class steward is Patient Administration
    An association between a patient encounter and a location.

    Attribute definitions for: Location_encounter_role

    accommodation_cd

    A code depicting the type of accommodation associated with this patient encounter.

    |PV2^2^00182^Accommodation Code|

    effective_dttm

    Date the association between the patient encounter and the facility location becomes effective.

    location_role_cd

    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.

    status_cd

    The status of location encounter role.

    termination_dttm

    Date the association between the facility location and the patient encounter ends.

    transfer_reason_cd

    A code depicting the reason for the patient transfer.

    |PV2^4^00184^Transfer Reason|

    transfer_reason_desc

    Descriptive text providing the reason for a transfer associated with the patient encounter.

    usage_approved_ind

    A indication that use of the location has been approved.

    Connection definitions for: Location_encounter_role

    pertains_to (1,1) :: Patient_encounter :: has (1,n)

    pertains_to (1,1) :: Patient_service_location :: has (0,n)

    Class: Master_calculated_observation

    Description of: Master_calculated_observation

    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.

    Attribute definitions for: Master_calculated_observation

    derivation_rule_desc

    A specification of the derivation rules for determining patient variables that are derived from one or more other patient variables.

    |OM6^2^00657^Derivation Rule|

    Class: Master_categorical_observation

    Description of: Master_categorical_observation

    Class steward is Orders/Observation
    A test/observation service for which categorical values results are generated.

    Attribute definitions for: Master_categorical_observation

    abnormal_result_cd

    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|

    allowed_value_type_cd

    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|

    critical_result_cd

    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_result_cd

    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_cd

    Preferred coding system for observations whose categorical responses are taken from a specified table of codes.

    |OM3^2^00636^Preferred Coding System|

    valid_answer_cd

    a list of valid coded answers

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    |OM3^3^00637^Valid Coded "Answers"|

    Class: Master_continuous_observation

    Description of: Master_continuous_observation

    Class steward is Orders/Observation
    A test/observation service for which continuous value results are generated.

    Attribute definitions for: Master_continuous_observation

    corresponding_SI_unit_of_measure_cd

    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|

    customary_unit_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|

    delta_check_numeric_change_computation_method_txt

    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|

    delta_check_numeric_change_threshold_nm

    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|

    delta_check_numeric_high_value_nm

    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|

    delta_check_numeric_low_value_nm

    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|

    delta_check_numeric_retention_days_qty

    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|

    length_and_decimal_precision_nm

    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|

    minimum_meaningful_increment_nm

    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|

    si_conversion_factor_txt

    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|

    Connection definitions for: Master_continuous_observation

    conforms_to (0,n) :: Master_numeric_range :: applies_to (1,1)

    Rationale: Streamlined modeling of numeric ranges.

    Class: Master_numeric_range

    Description of: Master_numeric_range

    Class steward is Orders/Observation
    A defined range of possible results for a continuous valued numeric observation/test.

    Rationale: Streamlined modeling of numeric ranges.

    Attribute definitions for: Master_numeric_range

    condition_desc

    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|

    high_gestation_age_amt

    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|

    high_range_amt

    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|

    high_value_nm

    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|

    low_age_amt

    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|

    low_gestation_age_amt

    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|

    low_value_nm

    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|

    race_subspecies_txt

    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|

    range_type_cd

    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.

    sex_txt

    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|

    species_txt

    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|

    Connection definitions for: Master_numeric_range

    applies_to (1,1) :: Master_continuous_observation :: conforms_to (0,n)

    Rationale: Streamlined modeling of numeric ranges.

    Class: Master_observation_service

    Description of: Master_observation_service

    Class steward is Orders/Observation
    A type of service catalog item specific to observation services.

    Attribute definitions for: Master_observation_service

    instrument_id

    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|

    permitted_data_type_cd

    A code depicting the permitted format of the observation value.

    |OM1^3^00588^Permitted Data Types|

    processing_time_qty

    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|

    specimen_required_ind

    An indication that a specimen is required for this observation service type.

    |OM1^4^00589^Specimen Required|

    typical_turnaround_time_qty

    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|

    Connection definitions for: Master_observation_service

    has (0,n) :: Master_specimen_requirement :: is_specified_for (1,1)

    has_as_basis (0,n) :: Master_observation_service :: is_basis_for (0,n)

    is_basis_for (0,n) :: Master_observation_service :: has_as_basis (0,n)

    Class: Master_service

    Description of: Master_service

    Class steward is Orders/Observation
    An individual test observation, test observation battery or panel, individual medication, diet, or procedure.

    Attribute definitions for: Master_service

    allowable_processing_priority_cd

    one of the available priorities for performing the observation or test

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    |OM1^25^00610^Processing Priority|

    allowable_reporting_priority_cd

    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|

    billing_reference_txt

    The service catalog item billing reference information.

    challenge_information_txt

    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|

    confidentiality_cd

    A code depicting the level of confidentiality associated with the service catalog item.

    |OM1^30^00615^Confidentiality Code|

    effective_dt

    The date the service catalog item is effective.

    factors_that_may_affect_observation_desc

    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|

    fee_amt

    The service catalog fee amount.

    fixed_canned_message_cd

    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|

    imaging_measurement_modality_cd

    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|

    incompatible_change_dttm

    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|

    instrument_identifier_coding_system_name

    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|

    instrument_identifier_name

    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|

    interpretation_considerations_desc

    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|

    join_cd

    kind_of_quantity_observed_cd

    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|

    last_update_dttm

    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|

    method_cd

    A code depicting the service catalog item method.

    |OM1^14^00599^Coded Representation of Method|

    method_desc

    A textual description of the service catalog item method.

    |OM1^41^00626^Description of Test Methods|

    nature_of_service_cd

    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|

    observation_id_suffix_txt

    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|

    orderable_service_ind

    An indication that the service catalog item is an orderable service.

    |OM1^12^00597^Orderability|

    patient_preparation_desc

    A description of special patient preparation, diet, or medications for this service catalog item.

    |OM1^37^00622^Patient Preparation|

    point_versus_interval_cd

    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|

    portable_device_ind

    An indication that a portable device may be use for the test or observation service catalog item.

    |OM1^15^00600^Portable|

    preferred_ordering_method_txt

    Free form text describing the preferred ordering method for the service catalog item.

    preferred_scheduling_method_txt

    Free form text describing the preferred scheduling method for the service catalog item.

    procedure_medication_cd

    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|

    quantitytiming_qt

    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.

    report_display_order_txt

    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|

    required_credentials_desc

    A description of the credentials required for the service catalog item.

    service_alternate_id

    An alternate unique identifier for the service catalog item.

    Rationale: specific to this usage

    |OM1^7^00592^Other Test/Observation IDs for the Observation|

    service_alternate_identifier_coding_system_name

    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|

    service_alternate_identifier_name

    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|

    service_alternate_name_use_cd

    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|

    service_alternate_nm

    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|

    service_contraindication_code

    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|

    service_desc

    A description of the service catalog item.

    Rationale: specific to this usage

    |OM1^6^00591^Observation Description|

    service_performance_schedule_cd

    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|

    service_primary_nm

    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|

    service_requirement_desc

    A free form description of the service requirements for the service catalog item.

    service_type_cd

    A code used to categorize the service catalog item.

    standard_time_to_perform_dttm

    The norm for performing the service across organizational provider and client base.

    Rationale:

    OpenIssue:

    target_anatomic_site_cd

    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|

    target_of_service_cd

    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.

    universal_service_id

    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|

    universal_service_identifier_coding_system_name

    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|

    universal_service_identifier_name

    name for the service catalog item

    Rationale: required by components of V2.3 field

    OpenIssue:

    |RXD^2^00335^Dispense/Give Code|

    Connection definitions for: Master_service

    is_source (0,n) :: Master_service_relationship :: has_source (1,1)

    is_target (0,n) :: Master_service_relationship :: has_target (1,1)

    is_delivered_during (0,n) :: Service_event :: delivers (1,1)

    is_instantiated_as (0,n) :: Service_intent_or_order :: is_an_instance_of (1,1)

    is_produced_by (0,n) :: Producer_of_master_service :: produces (0,1)

    Rationale: support use of Producer ID in V2.3 OM1

    OpenIssue:

    is_covered_by (0,n) :: Healthcare_benefit_service :: provides_coverage_for (1,n)

    Class: Master_service_relationship

    Description of: Master_service_relationship

    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.

    Attribute definitions for: Master_service_relationship

    constraint_txt

    Textual description of any arbitrary constraint on the source service when participating in the target service.

    Rationale: Detail of a possible relationship between services.

    quantitytiming_qt

    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.

    reflex_testing_trigger_rules_desc

    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|

    relationship_type_cd

    Specifies the basis for the association of the source to the target.

    Rationale: Needed for relationship management

    Connection definitions for: Master_service_relationship

    has_source (1,1) :: Master_service :: is_source (0,n)

    has_target (1,1) :: Master_service :: is_target (0,n)

    Class: Master_specimen_requirement

    Description of: Master_specimen_requirement

    Class steward is Orders/Observation
    A specification of specimen requirements for test/observation service catalog items which require a specimen.

    Attribute definitions for: Master_specimen_requirement

    additive_cd

    A code for the additive required for the collected specimen used in the associated observation service type.

    |OM4^7^00647^Additive|

    container_desc

    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|

    container_preparation_desc

    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|

    container_volume_amt

    A specification of the containers volume capacity.

    |OM4^4^00644^Container Volume|

    derived_specimen_cd

    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|

    minimum_collection_volume_amt

    The amount of specimen needed by the most specimen sparing method.

    |OM4^11^00651^Minimum Collection Volume|

    normal_collection_volume_amt

    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_desc

    Special handling requirements for the collected specimen.

    |OM4^9^00649^Special Handling Requirements|

    specimen_priorities_cd

    The allowed priorities for obtaining the specimen.

    |OM4^13^00653^Specimen Priorities|

    specimen_retention_time_amt

    The usual time that a specimen for this observation service type is retained after the observation is completed.

    |OM4^14^00654^Specimen Retention Time|

    specimen_type_cd

    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|

    Connection definitions for: Master_specimen_requirement

    is_specified_for (1,1) :: Master_observation_service :: has (0,n)

    Class: Master_treatment_service

    Description of: Master_treatment_service

    Class steward is Orders/Observation
    An item in the formulary.

    Attribute definitions for: Master_treatment_service

    dea_level_cd

    The drug enforcement agency level for the pharmacy treatment service.

    drug_category_cd

    The drug category code of the pharmacy treatment service.

    formulary_status_cd

    A code depicting the formulary status of a dispensed medication.

    Rationale: should be determined in the catalog, not at each dispense

    medication_form_cd

    A code depicting the form of the medication comprising the pharmacy treatment service.

    pharmaceutical_class_cd

    The pharmaceutical class of the pharmacy treatment service.

    route_cd

    A code depicting the administration route for the pharmacy treatment service.

    therapeutic_class_cd

    A code depicting the therapeutic class of the pharmacy treatment service.

    Connection definitions for: Master_treatment_service

    is_ordered_on (0,n) :: Treatment_intent_or_order_revision :: orders (0,1)

    Rationale: link medication on pharmacy_service_order_item to service catalog

    OpenIssue:

    Class: Medicaid_coverage

    Description of: Medicaid_coverage

    Class steward is Patient Administration
    A type of healthcare coverage provided by a state medicaid program.

    Attribute definitions for: Medicaid_coverage

    aid_category_cd

    A code depicting the category of aid which make this person eligible for medicaid (e.g., aged, blind, disabled, families with dependent children, ...)

    case_id

    An identifier assigned to a medicaid family for administration as a case.

    |IN2^8^00479^Medicaid Case Number|

    effective_dt

    The date medicaid coverage becomes effective.

    termination_dt

    The date medicaid coverage terminates.

    Class: Medicare_coverage

    Description of: Medicare_coverage

    Class steward is Patient Administration
    A type of Healthcare coverage provided by the federal Medicare program.

    Attribute definitions for: Medicare_coverage

    effective_dt

    The date the person's medicare coverage becomes effective.

    eligibility_cd

    A code depicting the person's medicare eligibility type (e.g., age, disability, ESRD, ...).

    id

    A person's medicare coverage identifier (HICN).

    |IN2^6^00477^Medicare Health Ins Card Number|

    lifetime_res_delay_day_qty

    A delay prior to lifetime reserve days.

    |IN1^34^00459^Delay Before L. R. Day|

    lifetime_reserve_day_qty

    The number of lifetime reserve days remaining.

    |IN1^33^00458^Lifetime Reserve Days|

    medicare_coverage_type_cd

    A code indicating the type of medicare coverage (e.g., hospital, professional,...).

    program_type_cd

    A code depicting the medicare reimbursement type (e.g., GPPP Cost, GPPP Risk, PPS, ...).

    renal_cd

    A code indicating the renal status of the person's medicare coverage.

    termination_dt

    The date the person's medicare coverage is no longer in effect.

    Class: Notary_public

    Description of: Notary_public

    Class steward is Information Management (Medical Records)
    A role of a person that authenticates the signature of a party.

    Attribute definitions for: Notary_public

    effective_dt

    The date upon which the person assumed the role of notary public.

    notary_county_cd

    The county in which the notary is licensed.

    notary_state_cd

    The state in which the notary is licensed.

    termination_dt

    Date on which the person is no longer in the role of notary public.

    Connection definitions for: Notary_public

    is_a_role_of (1,1) :: Person :: takes_on_role_of (0,1)

    Class: Observation_intent_or_order

    Description of: Observation_intent_or_order

    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

    Attribute definitions for: Observation_intent_or_order

    patient_hazard_code

    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|

    reason_for_study_cd

    Text or code describing the reason for the observation order.

    Rationale: V2.3 field is CE datatype

    |OBR^31^00263^Reason For Study|

    relevant_clinical_information_txt

    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.|

    reporting_priority_cd

    A code indicating the reporting priority of the patient service order.

    specimen_action_cd

    A code identifying the action to be taken with respect to the specimen.

    |OBR^11^00245^Specimen Action Code|

    Class: Organization

    Description of: Organization

    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.

    Attribute definitions for: Organization

    organization_name_type_cd

    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|

    organization_nm

    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|

    standard_industry_class_cd

    The standard industry class code of the organization.

    Connection definitions for: Organization

    categorizes (0,n) :: Financial_transaction :: is_categorized_by (0,1)

    has_as_a_subdivision (0,n) :: Organization :: is_a_subdivision_of (0,1)

    takes_on_role_of (0,1) :: Insurer :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Identifier_issuing_authority :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Healthcare_provider_organization :: is_a_role_of (1,1)

    assigns (0,n) :: Encounter_drg :: is_assigned_by (1,1)

    is_a_subdivision_of (0,1) :: Organization :: has_as_a_subdivision (0,n)

    takes_on_role_of (0,1) :: Bad_debt_collection_agency :: is_a_role_of (1,1)

    Class: Originator

    Description of: Originator

    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:

    Connection definitions for: Originator

    is_a (1,1) :: Stakeholder :: takes_on_role_of (0,1)

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

    Class: Patient

    Description of: Patient

    Class steward is Patient Administration
    A person who may receive, is receiving, or has received Healthcare services.

    Attribute definitions for: Patient

    ambulatory_status_cd

    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|

    birth_order_number

    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|

    living_arrangement_cd

    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|

    living_dependency_cd

    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|

    multiple_birth_ind

    A indication as to whether the patient is part of a multiple birth.

    |PID^24^00127^Multiple Birth Indicator|

    newborn_baby_ind

    A indication that the patient is a newborn baby.

    |PV2^36^00737^Newborn Baby Indicator|

    organ_donor_ind

    An indication that the patient is an organ donor.

    |PD1^8^00760^Organ Donor|

    preferred_pharmacy_id

    The preferred pharmacy of the patient.

    Connection definitions for: Patient

    has (0,n) :: Administrative_patient_accident :: pertains_to (1,1)

    participates_in (0,n) :: Preferred_provider_participation :: has_as_care_recipient (1,1)

    is_target_of (0,n) :: Target_participation :: has_as_target (0,1)

    Rationale: Replaces associations: Patient may_be_the_subject_of order - Patient is_subject_of Clinical_observation - Patient has Goal.

    is_scheduled_by (0,n) :: Patient_slot :: is_a_scheduleable_unit_for (1,1)

    is_requested_by (0,n) :: Patient_appointment_request :: requests (1,1)

    is_a_role_of (1,1) :: Person :: takes_on_role_of (0,1)

    has (0,n) :: Healthcare_benefit_plan :: is_for (1,1)

    has_a_primary_provider (0,1) :: Individual_healthcare_practitioner :: is_the_primary_provider_for (0,n)

    has_as_a_contact (0,n) :: Contact_person :: is_a_contact_for (0,1)

    has (0,n) :: Patient_billing_account :: belongs_to (1,1)

    has_as_primary_facility (0,1) :: Patient_service_location :: is_primary_facility_for (0,n)

    has (0,n) :: Disability :: pertains_to (1,1)

    Rationale: 2.3 abstract message definition

    OpenIssue:

    is_source_for (0,n) :: Collected_specimen_sample :: is_sourced_from (0,1)

    has (0,n) :: Health_chart :: belongs_to (1,1)

    has (0,n) :: Patient_information_disclosure :: pertains_to (1,1)

    has (0,1) :: Administrative_patient_death :: pertains_to (1,1)

    is_involved_in (0,n) :: Patient_encounter :: involves (1,1)

    Class: Patient_admission

    Description of: Patient_admission

    Class steward is Patient Administration
    The beginning of an inpatient encounter.

    Attribute definitions for: Patient_admission

    admission_dttm

    The date and time of the patient was admitted into an inpatient facility.

    |PV1^44^00174^Admit Date/Time|

    admission_reason_cd

    A code depicting the reason for the inpatient admission.

    |PV2^3^00183^Admit Reason|

    admission_referral_cd

    A code depicting the type of referral associated with this inpatient admission.

    admission_source_cd

    A code indicating the source category associated with this inpatient encounter.

    |PV1^14^00144^Admit Source|

    admission_type_cd

    A code indicating the circumstance under which the patient was or will be admitted.

    |PV1^4^00134^Admission Type|

    patient_valuables_desc

    Text describing the patient valuables left for safe keeping.

    |PV2^5^00185^Patient Valuables|

    pre_admit_test_ind

    An indication that pre-admission tests are required for this inpatient encounter.

    |PV1^12^00142^Preadmit Test Indicator|

    readmission_ind

    An indication that the inpatient encounter is a readmission.

    |PV1^13^00143^Readmission Indicator|

    valuables_location_desc

    Descriptive text identifying where valuables of patient is located.

    |PV2^6^00186^Patient Valuables Location|

    Connection definitions for: Patient_admission

    preceded (1,1) :: Inpatient_encounter :: is_preceded_by (1,1)

    Class: Patient_appointment_request

    Description of: Patient_appointment_request

    A request for a service to be performed for a specific patient. Rationale: Specializes the request for the patient as a resource. OpenIssue:

    Connection definitions for: Patient_appointment_request

    requests (1,1) :: Patient :: is_requested_by (0,n)

    Class: Patient_arrival

    Description of: Patient_arrival

    Class steward is Patient Administration
    The arrival of a patient at the location of care for a patient encounter.

    Attribute definitions for: Patient_arrival

    acuity_level_cd

    A code depicting the acuteness of the patients medical condition upon arrival.

    arrival_dttm

    The date and time of the patient arrival at the care location.

    arrival_type_cd

    A code classifying the types of patient arrivals.

    medical_service_id

    A unique identifier assigned to the medical service anticipated in the patient encounter.

    source_of_arrival_cd

    A code depicting the source of arrival.

    transport_mode_cd

    A code depicting the mode of transportation used to transport the patient to the care location.

    Connection definitions for: Patient_arrival

    precedes (1,1) :: Patient_encounter :: is_preceded_by (0,1)

    Class: Patient_billing_account

    Description of: Patient_billing_account

    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.

    Attribute definitions for: Patient_billing_account

    account_id

    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|

    adjustment_cd

    A code depicting the type of adjustment applied to the patient billing account.

    |PV2^30^00731^Patient Charge Adjustment Code|

    authorization_information_txt

    The authorization number or code received from the insurance company.

    |IN1^14^00439^Authorization Information|

    billing_status_cd

    A code indicating the status of billing.

    |IN1^32^00457^Billing Status| |PV1^41^00171^Account Status|

    certification_required_ind

    A indicator as to whether a certification is required.

    |IN3^4^00505^Certification Required|

    current_unpaid_balance_amt

    The current unpaid balance of a patient account.

    |PV1^46^00176^Current Patient Balance|

    delete_dt

    The date the patient billing account was deleted.

    |PV1^35^00165^Delete Account Date|

    deleted_account_reason_cd

    A code depicting the reason a patient billing account has been deleted.

    |PV1^34^00164^Delete Account Indicator|

    expected_insurance_plan_qty

    A count of the number of insurance plans expected to provide insurance coverage for this patient account.

    expected_payment_source_cd

    A code indicating the expected payment source.

    notice_of_admission_dt

    The date a notice of admission was sent.

    |IN1^24^00449^Notice of Admission Date|

    notice_of_admission_ind

    A indicator documenting whether the insurance company requires a written notice of admission.

    |IN1^23^00448^Notice of Admission Flag|

    patient_financial_class_cd

    A code depicting a category for the source of payment.

    |PV1^20^00150^Financial Class|

    price_schedule_id

    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|

    purge_status_cd

    A code depicting the purge status of the patient billing account.

    |PV2^16^00717^Purge Status Code|

    purge_status_dt

    The date the patient billing account was purged.

    |PV2^17^00718^Purge Status Date|

    report_of_eligibility_dt

    The date a report of eligibility was received.

    retention_ind

    A indicator to control the purge of the patient billing account and related data.

    signature_on_file_dt

    The date authorization to bill was obtained.

    |PV2^28^00729^Signature on File Date|

    special_program_cd

    A code indicating a special program governing the billing account.

    |PV2^18^00719^Special Program Code|

    stoploss_limit_ind

    A indicator identifying whether the patient has reached the stoploss limit established in the contract master.

    |IN2^68^00808^Stoploss Limit Flag|

    suspend_charges_ind

    An indicator as to whether charges should be suspended for a patient.

    |IN2^66^00806^Suspend Flag|

    total_adjustment_amt

    The total amount of the adjustment made to the patient billing account.

    |PV1^48^00178^Total Adjustments|

    total_charge_amt

    The total charge amount of the patient billing account.

    |PV1^47^00177^Total Charges|

    total_payment_amt

    The total of the payments made on a patient billing account.

    |PV1^49^00179^Total Payments|

    Connection definitions for: Patient_billing_account

    has_payment_guaranteed_by (0,n) :: Guarantor_contract :: provides_payment_guarantee_for (0,n)

    has_charges_for (0,n) :: Service_event :: is_charged_to (0,1)

    has_as_a_prior_account (0,1) :: Patient_billing_account :: is_the_prior_account_for (0,1)

    belongs_to (1,1) :: Patient :: has (0,n)

    is_billed_from (0,n) :: Service_intent_or_order :: is_billed_to (0,1)

    Rationale: supports use of BLG segment in the ORM message

    OpenIssue: Open issue: needs joint work with OO-PAFM

    has (0,n) :: Billing_information_item :: pertains_to (1,1)

    has (0,n) :: Financial_transaction :: is_associated_with (1,1)

    is_the_prior_account_for (0,1) :: Patient_billing_account :: has_as_a_prior_account (0,1)

    Class: Patient_departure

    Description of: Patient_departure

    Class steward is Patient Administration
    The end of a inpatient encounter.

    Attribute definitions for: Patient_departure

    discharge_disposition_cd

    A code depicting the disposition of the patient following discharge.

    |PV1^36^00166^Discharge Disposition|

    discharge_dttm

    The date and time that the patient is discharged from an inpatient facility.

    discharge_location_id

    An identifier assigned to the discharge location.

    |PV1^37^00167^Discharged to Location|

    expected_discharge_disp_cd

    A code depicting the expected disposition of the patient upon discharge.

    |PV2^27^00728^Expected Discharge Disposition|

    Connection definitions for: Patient_departure

    terminates (1,1) :: Inpatient_encounter :: is_terminated_by (0,1)

    Class: Patient_encounter

    Description of: Patient_encounter

    Class steward is Patient Administration
    An interaction between a patient and a Healthcare participant for the purpose of providing patient services or assessing the health status of a patient.

    Attribute definitions for: Patient_encounter

    administrative_outcome_txt

    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, . . .).

    cancellation_reason_cd

    A code depicting the reason for cancellation of an encounter.

    desc

    A textual description of the patient encounter.

    |PV2^12^00713^Visit Description|

    encounter_classification_cd

    A classification of a patient encounter.

    |PV2^7^00187^Visit User Code|

    end_dttm

    The date and time that the patient encounter ends.

    |PV1^45^00175^Discharge Date/Time|

    expected_insurance_plan_qty

    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|

    first_similar_illness_dt

    The date the patient first experienced a similar illness. Used to determine pre-existing conditions

    |PV2^29^00730^First Similar Illness Date|

    follow_up_type_cd

    A code indicating the type of follow-up required after completion of the patient encounter.

    |PV1^10^00140^Hospital Service|

    id

    A unique identifier assigned to the patient encounter.

    |PV1^19^00149^Visit Number| |PV1^50^00180^Alternate Visit ID|

    patient_classification_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|

    priority_cd

    A code depicting the relative priority of the patient encounter.

    |PV2^25^00726^Visit Priority Code|

    purpose_cd

    A code depicting the purpose of the patient encounter.

    record_signing_dttm

    The data and time the documentation of the patient encounter is signed.

    special_courtesies_ind

    An indication as to whether or not the patient is to be extended special courtesies.

    |PV1^22^00152^Courtesy Code|

    start_dttm

    The date and time that the patient encounter begins.

    status_cd

    A code depicting the status of the patient encounter.

    |PV2^24^00725^Patient Status Code|

    transport_requirement_cd

    A code depicting the type of transportation required or arranged for the transport of the patient (e.g., stretcher, wheelchair, ambulance, taxi, . . .).

    triage_classification_cd

    The triage classification of the patient during an encounter.

    Rationale: This attribute is related to an encounter rather than to the patient in general

    urgency_cd

    A code depicting the urgency of the patient encounter.

    Connection definitions for: Patient_encounter

    follows (0,n) :: Patient_encounter :: precedes (0,1)

    has (0,n) :: Administrative_patient_accident :: is_present_in (1,n)

    Rationale: Allows removal of generalization (patient_clinical_item) with single specialization

    involves (1,1) :: Patient :: is_involved_in (0,n)

    is_authorized_by (0,1) :: Preauthorization :: authorizes (1,n)

    is_scheduled_by (0,n) :: Appointment :: schedules (1,n)

    has_as_participant (1,n) :: Encounter_practitioner :: is_associated_with (1,1)

    has (1,n) :: Location_encounter_role :: pertains_to (1,1)

    has (0,n) :: Risk_management_incident :: pertains_to (1,1)

    has_assigned_to_it (0,n) :: Service_event :: is_assigned_to (0,1)

    Rationale: Establish independence of service events from encounters.

    precedes (0,1) :: Patient_encounter :: follows (0,n)

    is_preceded_by (0,1) :: Patient_arrival :: precedes (1,1)

    Whole-part definitions for: Patient_encounter

    has_parts (0,n) :: Administrative_birth_event :: is_part_of (1,1)

    is_part_of (1,1) :: Episode :: has_parts (1,n)

    Class: Patient_information_disclosure

    Description of: Patient_information_disclosure

    Class steward is Patient Administration
    A release of patient information to a third party.

    Attribute definitions for: Patient_information_disclosure

    disclosure_dttm

    The data and time of the disclosure.

    info_disclosed_desc

    Free form textual description of the information disclosed.

    info_requested_desc

    Free form text description of the requested information.

    reason_cd

    A code indicating why information about the patient was disclosed.

    requested_dttm

    Date the disclosed patient information was requested.

    urgency_cd

    A code indicating the priority of the request by a requester.

    Connection definitions for: Patient_information_disclosure

    pertains_to (1,1) :: Patient :: has (0,n)

    is_provided_to (1,1) :: Patient_information_recipient :: is_the_recipient_of (0,n)

    Class: Patient_information_recipient

    Description of: Patient_information_recipient

    Class steward is Patient Administration
    A role played by the stakeholder. This role is the recipient of patient information.

    Connection definitions for: Patient_information_recipient

    is_the_recipient_of (0,n) :: Patient_information_disclosure :: is_provided_to (1,1)

    is_a_role_of (1,1) :: Stakeholder :: takes_on_role_of (0,1)

    Class: Patient_service_location

    Description of: Patient_service_location

    Class steward is Patient Administration
    A place where patient services are delivered.

    OpenIssue: This class currently combines patient service event location information and location master file information. Should it be broken into separate classes.

    Attribute definitions for: Patient_service_location

    addr

    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_dt

    Closing date of the location.

    description

    optional freetext description of the location

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    |LOC^2^00944^Location Description|

    email_address

    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

    id

    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|

    licensed_bed_qty

    The number of licensed beds at the location.

    nm

    name of the location.

    opening_dt

    Opening date of the location.

    phon

    Phone at the location.

    |LOC^6^00949^Location Phone|

    service_specialty_cd

    The specialty code of the service.

    OpenIssue: This attribute may move to a masterfile class later.

    |LDP^4^00966^Speciality Type|

    slot_size_increment_qty

    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?

    status_cd

    A code indicating the status of the location.

    |NPU^2^00170^Bed Status| |PV1^40^00170^Bed Status|

    type_cd

    A code indicating the type of patient care location (e.g., hospital, clinic, hospital ward, room, bed, . . .).

    |LOC^3^00945^Location Type-LOC|

    Connection definitions for: Patient_service_location

    is_target_for (0,n) :: Target_participation :: has_as_target (0,1)

    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.

    is_requested_by (0,n) :: Patient_service_location_request :: requests (1,1)

    is_primary_facility_for (0,n) :: Patient :: has_as_primary_facility (0,1)

    is_entry_location_for (0,n) :: Service_intent_or_order :: is_entered_at (1,1)

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    includes (0,n) :: Patient_service_location :: is_included_in (0,1)

    belongs_to (0,n) :: Patient_service_location_group :: contains (1,n)

    has (0,n) :: Location_encounter_role :: pertains_to (1,1)

    is_included_in (0,1) :: Patient_service_location :: includes (0,n)

    is_location_for (0,n) :: Service_event :: is_performed_at (0,1)

    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.

    is_scheduled_by (0,n) :: Patient_service_location_slot :: is_a_scheduleable_unit_for (1,1)

    houses (0,n) :: Health_chart :: is_housed_at (1,1)

    provides_services_on_behalf_of (1,n) :: Healthcare_provider_organization :: provides_patient_services_at (0,n)

    Class: Patient_service_location_group

    Description of: Patient_service_location_group

    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:

    Attribute definitions for: Patient_service_location_group

    id

    Unique identifier for the group

    Rationale: Currently in 2.3

    OpenIssue:

    Connection definitions for: Patient_service_location_group

    is_requested_by (0,n) :: Patient_service_location_request :: may_request (0,1)

    contains (1,n) :: Patient_service_location :: belongs_to (0,n)

    Class: Patient_service_location_request

    Description of: Patient_service_location_request

    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

    Attribute definitions for: Patient_service_location_request

    type_cd

    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|

    Connection definitions for: Patient_service_location_request

    requests (1,1) :: Patient_service_location :: is_requested_by (0,n)

    may_request (0,1) :: Patient_service_location_group :: is_requested_by (0,n)

    Class: Patient_service_location_slot

    Description of: Patient_service_location_slot

    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:

    Connection definitions for: Patient_service_location_slot

    is_a_scheduleable_unit_for (1,1) :: Patient_service_location :: is_scheduled_by (0,n)

    Class: Patient_slot

    Description of: Patient_slot

    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:

    Connection definitions for: Patient_slot

    is_a_scheduleable_unit_for (1,1) :: Patient :: is_scheduled_by (0,n)

    Class: Person

    Description of: Person

    Class steward is Patient Administration
    A type of stakeholder. An individual human being.

    Attribute definitions for: Person

    birth_dttm

    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|

    birthplace_addr

    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|

    citizenship_country_cd

    The current citizenship of a person.

    |GT1^35^00129^Citizenship| |IN2^33^00129^Citizenship| |NK1^19^00129^Citizenship| |PID^26^00129^Citizenship|

    confidentiality_constraint_cd

    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| |PV2^21^00722^Visit Publicity Code|

    deceased_dttm

    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|

    deceased_ind

    A indication that the person is dead.

    |GT1^25^00776^Guarantor Death Flag| |PID^30^00741^Patient Death Indicator|

    disability_cd

    A code identifying a person disability.

    |GT1^52^00753^Handicap| |IN1^48^00753^Handicap| |NK1^36^00753^Handicap| |PD1^6^00753^Handicap|

    education_level_cd

    The amount of education a person achieved.

    ethnic_group_cd

    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|

    gender_cd

    A code depicting the gender (sex) of a person.

    |GT1^9^00413^Guarantor Sex| |IN1^43^00468^Insured's Sex| |NK1^15^00111^Sex| |PID^8^00111^Sex| |STF^5^00111^Sex|

    language_cd

    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|

    marital_status_cd

    A code depicting the marital status of a person.

    |GT1^30^00781^Guarantor Marital Status Code| |IN2^43^00119^Marital Status| |NK1^14^00119^Marital Status| |PID^16^00119^Marital Status| |STF^17^00119^Marital Status|

    military_branch_of_service_cd

    A person's military branch of service.

    |IN2^14^00485^Champus Service|

    military_rank_nm

    The name of a person's military rank.

    |IN2^15^00486^Champus Rank/Grade|

    military_status_cd

    The military status of a person.

    |PID^27^00130^Veterans Military Status|

    nationality_cd

    A code depicting the nationality of a person.

    |GT1^43^00739^Nationality| |IN2^41^00739^Nationality| |NK1^27^00739^Nationality| |PID^28^00739^Nationality|

    primary_name_representation_cd

    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:

    primary_name_type_cd

    Represents the type of name, e.g., Alias, Legal, Display ...

    Rationale: required by components of V2.3 field

    OpenIssue:

    primary_prsnm

    The primary name of a person.

    |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|

    race_cd

    A code depicting the race of a person.

    |IN2^71^00113^Race| |NK1^35^00113^Race| |PID^10^00113^Race|

    religious_affiliation_cd

    A person's religious preference.

    |GT1^41^00120^Religion| |IN2^39^00120^Religion| |NK1^25^00120^Religion| |PID^17^00120^Religion|

    student_cd

    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|

    very_important_person_cd

    An indication of the person's VIP type, for example, board member, diplomat, etc..

    |PV1^16^00146^VIP Indicator|

    Connection definitions for: Person

    takes_on_role_of (0,1) :: Individual_healthcare_practitioner :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Employee :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Contact_person :: is_a_role_of (1,1)

    has (0,n) :: Person_alternate_name :: is_for (1,1)

    takes_on_role_of (0,1) :: Notary_public :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Patient :: is_a_role_of (1,1)

    enters (0,n) :: Financial_transaction :: is_entered_by (1,1)

    may_act_in_the_role_of (0,1) :: Transcriptionist :: is_identified_as (1,1)

    has (0,1) :: Administrative_birth_event :: pertains_to (1,1)

    Class: Person_alternate_name

    Description of: Person_alternate_name

    Class steward is Patient Administration
    A additional name by which a person is or has been known.

    Attribute definitions for: Person_alternate_name

    effective_dt

    The effective date of the person's alternate name.

    name_representation_code

    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

    prsnm

    Other names by which a person is known.

    |IN2^7^00478^Medicaid Case Name| |PID^9^00112^Patient Alias|

    reason_cd

    A code indicating the reason the alternate person name is used.

    termination_dt

    The termination date of the person's alternate name.

    type_cd

    A code indicating the type of alternate name (e.g., nickname, alias, maiden name, legal, adopted, . . .).

    Connection definitions for: Person_alternate_name

    is_for (1,1) :: Person :: has (0,n)

    is_used_by (0,n) :: Stakeholder :: refers_to_person_by (0,n)

    Class: Person_employment

    Description of: Person_employment

    Class steward is Patient Administration
    The state of being employed. An occupation by which a person earns a living; work; business.

    Attribute definitions for: Person_employment

    addr

    address of the person's work site.

    |GT1^17^00421^Guarantor Employer Address| |IN1^44^00469^Insured's Employer Address| |NK1^4^00193^Address|

    effective_dt

    The date the person's employment begins.

    |GT1^31^00782^Guarantor Hire Effective Date| |IN2^44^00787^Insured's Employment Start Date|

    hazard_exposure_txt

    The type of hazards a person is exposed to in their employment.

    job_class_cd

    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|

    job_status_cd

    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|

    job_title_nm

    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|

    occupation_cd

    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|

    phon

    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_txt

    Protective equipment needed for employment.

    salary_amt

    A person's salary amount.

    salary_type_cd

    A salary type (e.g., hourly, annual, commission, . . .).

    status_cd

    A code depicting the status of the person's employment.

    |GT1^20^00424^Guarantor Employment Status| |IN1^42^00467^Insured's Employment Status|

    termination_dt

    Date the person's employment ends.

    |GT1^32^00783^Guarantor Employment Stop Date| |IN2^45^00783^Guarantor Employment Stop Date|

    Connection definitions for: Person_employment

    has_as_employer (1,1) :: Employer :: is_employer_of (0,n)

    has_as_employee (1,1) :: Employee :: is_employee_in (0,n)

    Class: Preauthorization

    Description of: Preauthorization

    Class steward is Patient Administration
    An authorization for patient services by a third party prior to the delivery of the patient service.

    Attribute definitions for: Preauthorization

    authorized_encounters_amt

    The number of authorized encounters.

    authorized_period_begin_dt

    The date the authorized period begins.

    authorized_period_end_dt

    The end date of the authorized period.

    id

    A unique identifier assigned to the pre authorization.

    Rationale: IN1-28

    OpenIssue:

    |IN1^28^00453^Pre-Admit Cert (PAC)|

    issued_dttm

    The date and time the pre authorization is issued.

    requested_dttm

    The date and time the preauthorization was created.

    restriction_desc

    A description of restrictions associated with the preauthorization.

    status_cd

    A code depicting the status of a preauthorization.

    status_change_dttm

    The date and time of the last status change.

    Connection definitions for: Preauthorization

    authorizes (1,n) :: Patient_encounter :: is_authorized_by (0,1)

    is_issued_by (1,1) :: Insurer :: issues (0,n)

    Class: Preferred_provider_participation

    Description of: Preferred_provider_participation

    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).

    Attribute definitions for: Preferred_provider_participation

    role_cd

    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).

    Connection definitions for: Preferred_provider_participation

    has_as_care_provider (1,1) :: Healthcare_service_provider :: participates_in (0,n)

    Rationale: A person's PCP can be either a practitioner or a provider organization.

    has_as_care_recipient (1,1) :: Patient :: participates_in (0,n)

    is_governed_by (0,1) :: Healthcare_benefit_plan :: governs (0,n)

    Class: Problem

    Description of: Problem

    Class steward is Patient Care
    A problem addressed by a patient pathway.

    Attribute definitions for: Problem

    action_cd

    Event reason for including the problem

    Rationale:

    OpenIssue:

    |GOL^1^00816^Action Code| |PRB^1^00816^Action Code| |PTH^1^00816^Action Code| |ROL^2^00816^Action Code|

    action_dttm

    Event date time

    Rationale:

    OpenIssue:

    |GOL^2^00817^Action Date/Time| |PRB^2^00817^Action Date/Time|

    actual_resolution_dttm

    The date the patient problem is resolved.

    classification_cd

    A code used to categorize the patient problem.

    confirmation_status_cd

    A code depicting the level of verification for the patient problem (e.g., confirmed, differential, provisional, rule-out, . . .).

    currently_active_ind

    A indication that the patient problem is an active problem.

    Rationale: Each Patient_problem instance in RIM084 becomes a new assessment service event under USAMP

    established_dttm

    Date time the problem was documented and thus established as a problem

    Rationale: Conformance with 2.3

    OpenIssue:

    |PRB^7^00842^Date/Time Problem Established|

    estimated_resolution_dttm

    The estimated date and time of the patient problem resolution.

    family_awareness_desc

    An indication of the patient's family or significant other's comprehension of the actual problem/prognosis.

    individual_awareness_cd

    A indication of the patient's comprehension of the problem.

    institutional_sensitivity_cd

    A code depicting the level of security or sensitivity surrounding the problem_diagnosis as assigned by the institution

    Rationale: Clarify authority for the code.

    life_cycle_status_dttm

    The effective data and time of the current problem status.

    lifecycle_status_cd

    A code depicting the current status of the problem (e.g., active, active-improving, active-stable, active-worsening, inactive, resolved, . . .).

    management_discipline_cd

    A code depicting the caregiver discipline responsible for managing the patient problem.

    nm

    Standard code or name for the problem_diagnosis.

    Rationale: Each Patient_problem instance in RIM)84 becomes a new assessment service event under USAMP

    onset_desc

    A textual description of when the problem began.

    onset_dttm

    The date/time the patient problem began.

    persistence_cd

    A textual description of the perseverance of a master problem.

    prefix_qualifier_txt

    A prefix modifying the problem identified by the patient problem identifier.

    Rationale: Each Patient_problem instance in RIM084 becomes a new assessment service event under USAMP.

    probability_pct

    A quantitative numerical representation of the certainty that the problem exist for the patient.

    problem_certainty_txt

    A qualitative representation of the certainty of the problem (e.g., high, medium, low, . . .).

    problem_list_priority_num

    Priority of the problem within the scope of the entire problem list.

    Rationale: Conformance with 2.3

    OpenIssue:

    |PRB^6^00841^Problem List Priority|

    prognosis_awareness_desc

    A indication of the patient's awareness of the prognosis for the problem.

    prognosis_desc

    A textual description of the prognosis for a patient problem.

    ranking_desc

    Prioritization of the problem (e.g., numeric ranking or the use of words such as primary, secondary, . . .).

    severity_cd

    A code depicting the severity of the patient's problem_diagnosis.

    Rationale: Each Patient_problem instance inRIM084 becomes a new assessment service event under USAMP.

    suffix_qualifier_txt

    A suffix modifying the problem identified by the patient problem identifier.

    Rationale: Each Patient_problem instance in RIM084 becomes a new assessment service event under USAMP.

    Connection definitions for: Problem

    specified_in (0,1) :: Episode :: specfies (0,n)

    Class: Procedure

    Description of: Procedure

    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.

    Attribute definitions for: Procedure

    anesthesia_cd

    A code identifying the anesthesia used in a procedure.

    |PR1^9^00399^Anesthesia Code|

    anesthesia_minutes_qty

    A count of the anesthesia minutes involved in the procedure.

    |PR1^10^00400^Anesthesia Minutes|

    delay_reason_txt

    The reason for delay of the surgery patient service.

    incision_closed_dttm

    The data and time of the closing incision of the surgery patient service.

    incision_open_dttm

    The data and time of the opening incision of the surgery patient service.

    modifier_cd

    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.

    priority_number

    A number indicating the relative priority of the procedure to all other procedures provided in this encounter.

    |PR1^14^00404^Procedure Priority|

    procedure_cd

    A code used to identify a procedure.

    |CDM^7^00393^Procedure Code| |FT1^25^00393^Procedure Code| |PR1^3^00393^Procedure Code|

    procedure_dttm

    The date/time of the procedure.

    |PR1^5^00395^Procedure Date/Time|

    procedure_functional_type_cd

    A code identifying the functional type of the procedure.

    |PR1^6^00396^Procedure Functional Type|

    procedure_minute_qty

    The length of the procedure, measured in minutes.

    |PR1^7^00397^Procedure Minutes|

    Connection definitions for: Procedure

    collects (0,n) :: Collected_specimen_sample :: is_collected_during (0,1)

    Rationale: Add Procedure as possible source of specimen.

    Class: Producer_of_master_service

    Description of: Producer_of_master_service

    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?

    Attribute definitions for: Producer_of_master_service

    service_producing_department_type_cd

    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|

    Connection definitions for: Producer_of_master_service

    produces (0,1) :: Master_service :: is_produced_by (0,n)

    Rationale: support use of Producer ID in V2.3 OM1

    OpenIssue:

    has_as_participant (1,1) :: Healthcare_service_provider :: participates_as (0,n)

    Class: Referral

    Description of: Referral

    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.

    Attribute definitions for: Referral

    authorized_visits_qty

    The number of authorized referral visits.

    desc

    Free form text describing the referral.

    reason_txt

    Free form text providing the reason for the referral.

    Class: Resource_request

    Description of: Resource_request

    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:

    Attribute definitions for: Resource_request

    allowable_substitutions_cd

    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|

    duration_qty

    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|

    start_dttm

    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|

    start_offset_qty

    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:

    status_cd

    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|

    Connection definitions for: Resource_request

    is_requested_by (1,1) :: Appointment_request :: requests (0,n)

    Class: Resource_slot

    Description of: Resource_slot

    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:

    Attribute definitions for: Resource_slot

    offset_qty

    Offset from start date and time when this allocated use will begin

    Rationale: future

    OpenIssue:

    quantity

    Number of slots allocated to a given purpose

    Rationale: future

    OpenIssue:

    resource_type_cd

    Type of resource controlled by this set of slots: provider, location, or equipment.

    Rationale: future

    OpenIssue:

    slot_state_cd

    Current status for this set of slots: available, booked, or blocked.

    Rationale: future

    OpenIssue:

    start_dttm

    Start date and time for this set of slots

    Rationale: future

    OpenIssue:

    Connection definitions for: Resource_slot

    is_reserved_by (0,n) :: Appointment :: reserves (0,n)

    Links a schedule to its contents.

    is_managed_by (1,1) :: Schedule :: contains (0,n)

    Class: Risk_management_incident

    Description of: Risk_management_incident

    Class steward is Patient Administration
    An occurrence of an event pertaining or attaching to a patient encounter.

    Attribute definitions for: Risk_management_incident

    incident_cd

    A code depicting the incident type (e.g., body fluid exposure, equipment problem, inpatient fall, medication error, . . .).

    incident_dttm

    The date and time the incident occurred.

    incident_severity_cd

    A code depicting the potential impact of an incident on the quality of patient care.

    incident_type_cd

    A code depicting a classification of the incident type (e.g., preventable, user error, . . .).

    Connection definitions for: Risk_management_incident

    pertains_to (1,1) :: Patient_encounter :: has (0,n)

    Class: Schedule

    Description of: Schedule

    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:

    Attribute definitions for: Schedule

    id

    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|

    Connection definitions for: Schedule

    contains (0,n) :: Appointment :: are_booked_in (1,n)

    contains (0,n) :: Resource_slot :: is_managed_by (1,1)

    Class: Service_event

    Description of: Service_event

    Class steward is Orders/Observation
    Interested committees Patient Administration
    The rendering of a Healthcare service to a patient.

    ISSUE: Should there be an Observation Service Event specialization Patient Service Event?

    Attribute definitions for: Service_event

    attestation_dttm

    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.

    attestation_due_dt

    The date attestation is due for this patient service.

    begin_dttm

    Date the patient service begins.

    |OBR^7^00241^Observation Date/Time| |RXA^3^00345^Date/Time Start of Administration|

    charge_to_practice_amt

    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_to_practice_cd

    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|

    consent_code

    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|

    declined_ind

    An indication that the patient service was declined.

    end_dttm

    The end date and time for the patient service.

    |OBR^8^00242^Observation End Date/Time| |RXA^4^00346^Date/Time End of Administration|

    filler_id

    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|

    filler_order_status_cd

    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|

    filler_order_status_dttm

    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|

    name

    patient_sensitivity_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

    recurring_service_cd

    A code indicating a recurring service and the nature of the recursion.

    |PV2^31^00732^Recurring Service Code|

    scheduled_start_dttm

    The date the patient service is scheduled to begin.

    |OBR^36^00268^Scheduled Date/Time|

    service_desc

    Text that describes the service performed along with relevant details of the service.

    Rationale: To differentiate this attribute from Service_event: service_event_desc.

    service_event_desc

    A description of the service event.

    specimen_action_cd

    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."

    specimen_received_dttm

    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|

    Connection definitions for: Service_event

    is_associated_with (0,n) :: Financial_transaction :: pertains_to (1,1)

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

    is_performed_at (0,1) :: Patient_service_location :: is_location_for (0,n)

    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.

    is_source_for (0,n) :: Service_event_relationship :: has_as_source (1,1)

    is_target_for (0,n) :: Service_event_relationship :: has_as_target (1,1)

    is_assigned_to (0,1) :: Patient_encounter :: has_assigned_to_it (0,n)

    Rationale: Establish independence of service events from encounters.

    has_as_reason (0,n) :: Service_reason :: is_reason_for (0,1)

    Rationale: Establish Service_reason as the reason for a Service_event.

    delivers (1,1) :: Master_service :: is_delivered_during (0,n)

    is_evidence_for (0,n) :: Service_reason :: has_as_evidence (0,1)

    Rationale: Establish Service_event as the evidence for a Service_reason.

    fulfills (0,1) :: Service_intent_or_order :: is_fulfilled_by (0,n)

    has_as_target (0,n) :: Target_participation :: is_target_of (0,1)

    is_charged_to (0,1) :: Patient_billing_account :: has_charges_for (0,n)

    has_as_active_participant (0,n) :: Active_participation :: participates_in (0,1)

    Class: Service_event_relationship

    Description of: Service_event_relationship

    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.

    Attribute definitions for: Service_event_relationship

    relationship_type_cd

    Specifies the basis for the association of the source to the target.

    Rationale: Relationship management.

    Connection definitions for: Service_event_relationship

    has_as_target (1,1) :: Service_event :: is_target_for (0,n)

    has_as_source (1,1) :: Service_event :: is_source_for (0,n)

    Class: Service_intent_or_order

    Description of: Service_intent_or_order

    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.

    Attribute definitions for: Service_intent_or_order

    charge_type_cd

    A code identifying someone or something other than the patient to be billed for this service.

    |BLG^2^00235^Charge Type|

    clarification_phone

    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|

    end_condition_cd

    A code depicting a condition that when satisfied should end the series of service orders.

    entering_device_code

    Identifier of the physical device (terminal,PC) used to enter the order

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    |ORC^18^00232^Entering Device|

    escort_required_indicator

    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|

    expected_performance_time_qty

    Time expected to perform this service instance for the target.

    Rationale:

    OpenIssue:

    filler_order_id

    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|

    filler_txt

    intent_or_order_cd

    Distinguishes an intent from an order.

    Rationale: There exists reasons that require being able to distinguish the two types of instances.

    join_cd

    order_control_code

    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|

    order_control_reason_code

    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|

    order_effective_dttm

    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|

    order_group_id

    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|

    order_id

    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|

    order_placed_dttm

    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|

    order_quantitytiming_qt

    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:

    placer_order_id

    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|

    placer_txt

    planned_patient_transport_code

    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|

    report_results_to_phone

    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|

    response_requested_cd

    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|

    results_status_cd

    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|

    service_body_site_code

    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|

    service_body_site_modifier_code

    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|

    service_body_source_code

    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|

    target_of_service_cd

    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.

    transport_arranged_indicator

    indicator of whether transport arrangements are known to have been made.

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    |OBR^41^01032^Transport Arranged|

    transport_arrangement_responsibility_code

    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|

    transport_mode_cd

    A code indicating how (or whether) to transport a patient.

    |OBR^30^00262^Transportation Mode|

    when_to_charge_dttm

    Date and time to charge for the ordered service.

    Rationale: required by components of V2.3 field

    OpenIssue:

    |BLG^1^00234^When to Charge|

    when_to_charge_text

    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|

    Connection definitions for: Service_intent_or_order

    is_fulfilled_by (0,n) :: Service_event :: fulfills (0,1)

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

    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.

    is_an_instance_of (1,1) :: Master_service :: is_instantiated_as (0,n)

    is_target_for (0,n) :: Service_intent_or_order_relationship :: has_as_target (1,1)

    is_source_for (0,n) :: Service_intent_or_order_relationship :: has_as_source (1,1)

    has_as_participant (0,n) :: Active_participation :: participates_in (0,1)

    is_billed_to (0,1) :: Patient_billing_account :: is_billed_from (0,n)

    Rationale: supports use of BLG segment in the ORM message

    OpenIssue: Open issue: needs joint work with OO-PAFM

    is_entered_at (1,1) :: Patient_service_location :: is_entry_location_for (0,n)

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    has_as_target (1,n) :: Target_participation :: is_target_of (0,1)

    has_as_reason (0,n) :: Service_reason :: is_reason_for (0,1)

    Rationale: Establish Service_reason as the reason for a Service_intent_or_order.

    Class: Service_intent_or_order_relationship

    Description of: Service_intent_or_order_relationship

    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.

    Attribute definitions for: Service_intent_or_order_relationship

    constraint_txt

    Textual description of any arbitrary constraint on the source when associated with the target.

    Rationale: Details of a possible relationship between services.

    quantitytiming_qt

    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.

    reflex_testing_trigger_rules_desc

    A description of the rules that trigger reflex testing for an intended or ordered service.

    Rationale: Detail of a possible relationship between services.

    relationship_type_cd

    Specifies the basis for the association of the source to the target.

    Rationale: Relationship management

    Connection definitions for: Service_intent_or_order_relationship

    has_as_target (1,1) :: Service_intent_or_order :: is_target_for (0,n)

    has_as_source (1,1) :: Service_intent_or_order :: is_source_for (0,n)

    Class: Service_reason

    Description of: Service_reason

    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.

    Attribute definitions for: Service_reason

    determination_dttm

    The date and time at which the determination is made that the reason applies.

    Rationale: Required to manage reasons.

    documentation_dttm

    The date and time at which the applicability of the reason is document.

    Rationale: Required to manage reasons.

    reason_txt

    Capture free text for the reason for a service event when the connection to another service event is not known (connection as a reason).

    Connection definitions for: Service_reason

    has_as_evidence (0,1) :: Service_event :: is_evidence_for (0,n)

    Rationale: Establish Service_event as the evidence for a Service_reason.

    is_reason_for (0,1) :: Service_event :: has_as_reason (0,n)

    Rationale: Establish Service_reason as the reason for a Service_event.

    is_reason_for (0,1) :: Service_intent_or_order :: has_as_reason (0,n)

    Rationale: Establish Service_reason as the reason for a Service_intent_or_order.

    Class: Service_request

    Description of: Service_request

    Class steward is Inter-Enterprise (ADT/Finance/Inter-Enterprise)
    Interested committees Patient Care
    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.

    Attribute definitions for: Service_request

    allowable_substitutions_cd

    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|

    duration_qty

    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|

    start_dttm

    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|

    start_offset_qty

    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|

    status_cd

    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|

    universal_service_id

    An identifier for the service which is being requested for scheduling.

    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|

    Connection definitions for: Service_request

    is_requested_by (1,1) :: Appointment_request :: requests (0,n)

    Class: Stakeholder

    Description of: Stakeholder

    Class steward is Patient Administration
    A person or organization that has an investment, share, or interest in healthcare.

    Attribute definitions for: Stakeholder

    addr

    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|

    credit_rating_cd

    A code depicting the credit rating of a stakeholder.

    |GT1^23^00774^Guarantor Credit Rating Code| |PV1^23^00153^Credit Rating|

    email_address_txt

    The email address of a stakeholder.

    phon

    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|

    type_cd

    A code depicting the type of stakeholder (e.g., person, organization, . . .).

    Connection definitions for: Stakeholder

    takes_on_role_of (0,1) :: Accident_information_source :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Insurance_certification_contact :: is_a_role_of (1,1)

    refers_to_person_by (0,n) :: Person_alternate_name :: is_used_by (0,n)

    may_act_as_a (0,1) :: Document_recipient :: is_a (1,1)

    takes_on_role_of (0,1) :: Patient_information_recipient :: is_a_role_of (1,1)

    participates_in (0,n) :: Active_participation :: has_as_participant (0,1)

    takes_on_role_of (0,1) :: Originator :: is_a (1,1)

    takes_on_role_of (0,1) :: Healthcare_document_authenticator :: is_a (1,1)

    takes_on_role_of (0,1) :: Health_benefit_plan_purchaser :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Guarantor :: is_a_role_of (1,1)

    takes_on_role_of (0,1) :: Employer :: is_a_role_of (1,1)

    participates_as_primary_in (0,n) :: Stakeholder_affiliation :: has_as_primary_participant (1,1)

    is_assigned (0,n) :: Stakeholder_identifier :: is_assigned_to (1,1)

    takes_on_role_of (0,1) :: Stakeholder_affiliate :: is_a_role_of (1,1)

    collects (0,n) :: Collected_specimen_sample :: is_collected_by (1,1)

    Class: Stakeholder_affiliate

    Description of: Stakeholder_affiliate

    Class steward is Patient Administration
    A person or organization which has an affiliation with another stakeholder.

    Attribute definitions for: Stakeholder_affiliate

    family_relationship_cd

    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|

    Connection definitions for: Stakeholder_affiliate

    is_a_role_of (1,1) :: Stakeholder :: takes_on_role_of (0,1)

    participates_as_secondary_in (0,n) :: Stakeholder_affiliation :: has_as_secondary_participant (1,1)

    Class: Stakeholder_affiliation

    Description of: Stakeholder_affiliation

    Class steward is Patient Administration
    A association between one stakeholder and another.

    Attribute definitions for: Stakeholder_affiliation

    affiliation_type_cd

    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|

    desc

    Description of the stakeholder affiliation.

    effective_dt

    The date the affiliation between the associated stakeholders begins.

    |IN2^55^00795^Relationship To The Patient Start Date| |NK1^8^00197^Start Date|

    termination_dt

    The date the affiliation between the associated stakeholders ends.

    |IN2^56^00796^Relationship To The Patient Stop Date| |NK1^9^00198^End Date|

    Connection definitions for: Stakeholder_affiliation

    has_as_primary_participant (1,1) :: Stakeholder :: participates_as_primary_in (0,n)

    has_as_secondary_participant (1,1) :: Stakeholder_affiliate :: participates_as_secondary_in (0,n)

    Class: Stakeholder_identifier

    Description of: Stakeholder_identifier

    Class steward is Patient Administration
    A unique identifier assigned to a person or organization.

    Attribute definitions for: Stakeholder_identifier

    effective_dt

    The effective date of the identifier.

    id

    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|

    identifier_type_cd

    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.

    issued_dt

    Date the identifier is issued.

    qualifying_information_txt

    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|

    termination_dt

    The date the identification is no longer in effect.

    Connection definitions for: Stakeholder_identifier

    is_assigned_to (1,1) :: Stakeholder :: is_assigned (0,n)

    is_issued_by (1,1) :: Identifier_issuing_authority :: issues (0,n)

    Class: Target_participation

    Description of: Target_participation

    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.

    Attribute definitions for: Target_participation

    begin_dttm

    The effective date and time of the target participation.

    Rationale: Manage target participatiions.

    duration

    The elapsed time during which the target participation is in effect.

    Rationale: Manage target participations.

    end_dttm

    The termination date and time for the target participation.

    Rationale: Manage target participations.

    participation_type_cd

    The nature of purpose of the target's participation. Examples: subject, beneficiary, receiver, user, specifier.

    Rationale: Manage target participations.

    Connection definitions for: Target_participation

    is_target_of (0,1) :: Service_event :: has_as_target (0,n)

    is_target_of (0,1) :: Service_intent_or_order :: has_as_target (1,n)

    has_as_target (0,1) :: Patient_service_location :: is_target_for (0,n)

    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.

    has_as_target (0,1) :: Patient :: is_target_of (0,n)

    Rationale: Replaces associations: Patient may_be_the_subject_of order - Patient is_subject_of Clinical_observation - Patient has Goal.

    has_as_target (0,1) :: Collected_specimen_sample :: is_target_of (0,n)

    Rationale: Replaces association Collected_specimen_sample is_used_during Service_event.

    Class: Transcriptionist

    Description of: Transcriptionist

    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:

    Connection definitions for: Transcriptionist

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

    is_identified_as (1,1) :: Person :: may_act_in_the_role_of (0,1)

    Class: Treatment_intent_or_order

    Description of: Treatment_intent_or_order

    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.

    Attribute definitions for: Treatment_intent_or_order

    dosage_txt

    The dosage to be administered.

    earliest_dispense_dt

    The earliest date the medication can be dispensed.

    Indication_cd

    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|

    non_form_authorized_ind

    An indication that a pharmacy order for an out of formulary item is authorized.

    providers_treatment_instruction_txt

    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|

    rejection_reason_cd

    A reason code for rejection of a pharmacy order.

    requested_give_rate_amt

    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|

    requested_give_strength_amt

    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|

    substitution_allowed_ind

    An indicator that a substitution medication is allowed.

    |RXO^9^00300^Allow Substitutions|

    supplier_special_dispensing_instruction_cd

    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|

    verification_required_ind

    An indication that verification is required.

    Whole-part definitions for: Treatment_intent_or_order

    has_parts (1,n) :: Treatment_intent_or_order_revision :: is_part_of (1,1)

    Class: Treatment_intent_or_order_revision

    Description of: Treatment_intent_or_order_revision

    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.

    Attribute definitions for: Treatment_intent_or_order_revision

    dispense_package_method_cd

    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|

    dispense_package_size_amt

    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|

    give_indication_cd

    condition or problem for which the drug/treatment was prescribed

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    |RXE^27^01128^Give Indication|

    give_per_time_unit_cd

    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)|

    give_rate_amt

    The rate of give for the medication.

    |RXE^23^00332^Give Rate Amount| |RXG^15^00332^Give Rate Amount|

    last_refilled_dttm

    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|

    max_give_amt

    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|

    min_give_amt

    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|

    needs_human_review_ind

    An indication that a pharmacy order for an out of formulary item is authorized.

    order_revision_PTcomp

    Specification for one component of the ordered medication or treatment

    Rationale:

    OpenIssue:

    |RXC^4^00316^Component Units|

    order_revision_PTrout

    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|

    order_revision_quantitytiming_qt

    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:

    ordered_administration_method_cd

    The method to be used to administer the medication.

    |RXR^4^00312^Administration Method|

    prescription_id

    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|

    providers_administration_instruction_cd

    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|

    refills_allowed_qty

    The number of refills doses dispensed.

    |RXE^17^00327^Number of Refills/Doses Dispensed|

    refills_doses_dispensed_qty

    The number of refills remaining.

    |RXD^8^00326^Number of Refills Remaining| |RXE^16^00326^Number of Refills Remaining|

    refills_remaining_qty

    The number of refills remaining.

    |RXD^8^00326^Number of Refills Remaining| |RXE^16^00326^Number of Refills Remaining|

    substitution_status_cd

    Substitution status of the pharmacy order.

    |RXD^11^00322^Substitution Status| |RXE^9^00322^Substitution Status| |RXG^10^00322^Substitution Status|

    suppliers_dispensing_instruction_cd

    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|

    total_daily_dose_amt

    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_dose_cd

    Total daily dosage code.

    |RXD^12^00329^Total Daily Dose| |RXE^19^00329^Total Daily Dose|

    Connection definitions for: Treatment_intent_or_order_revision

    orders (0,1) :: Master_treatment_service :: is_ordered_on (0,n)

    Rationale: link medication on pharmacy_service_order_item to service catalog

    OpenIssue:

    Whole-part definitions for: Treatment_intent_or_order_revision

    is_part_of (1,1) :: Treatment_intent_or_order :: has_parts (1,n)

    Class: Treatment_service_administration

    Description of: Treatment_service_administration

    Class steward is Orders/Observation
    Actual administration of medication as part of a pharmacy treatment.

    Attribute definitions for: Treatment_service_administration

    administered_rate_txt

    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)|

    completion_status_cd

    Status of treatment administration event

    Rationale: previously unmatched V2.3 field

    OpenIssue:

    |RXA^20^01223^Completion Status|

    substance_refusal_reason_cd

    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|

    substitution_cd

    A code indicating the medication was a substitution for the one ordered.

    system_entry_dttm

    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|

    Class: Treatment_service_dispense

    Description of: Treatment_service_dispense

    Class steward is Orders/Observation
    Notification of a pharmacy treatment dispense.

    Attribute definitions for: Treatment_service_dispense

    dispense_package_method_cd

    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|

    dispense_package_size_amt

    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|

    needs_human_review_ind

    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|

    rejection_reason_txt

    Free form text describing the reason the medication dispensement was rejected.

    substitution_cd

    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|

    suppliers_special_dispensing_instruction_cd

    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|

    total_daily_dose_amt

    The daily dose amount.

    Rationale: alignment with V2.3 language

    |RXD^12^00329^Total Daily Dose| |RXE^19^00329^Total Daily Dose|

    Class: Treatment_service_event

    Description of: Treatment_service_event

    Class steward is Orders/Observation
    A type of service event in which a pharmacy or treatment service is performed.

    Attribute definitions for: Treatment_service_event

    expiration_dttm

    Expiration date of the medication.

    Rationale: alignment with V2.3 language. Common to all specializations of Treatment_service.

    indication_cd

    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|

    notes_txt

    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|

    prescription_id

    An identifier assigned to the pharmacy treatment service event.

    |RXD^7^00325^Prescription Number| |RXE^15^00325^Prescription Number|

    PTcomp

    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|

    PTrout

    Specification for one component of the treatment service.

    Rationale: Common to all specializations of Treatment_service.

    OpenIssue:

    |RXR^3^00311^Administration Device|

    refills_remaining_qty

    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|

    substance_lot_number_txt

    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|

    substance_manufacturer_cd

    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|

    Class: Treatment_service_give

    Description of: Treatment_service_give

    Class steward is Orders/Observation
    The issuing of a pharmacy or treatment give notice.

    Attribute definitions for: Treatment_service_give

    administration_desc

    Free form text.

    |RXA^2^00344^Administration Sub-ID Counter| |RXG^13^00343^Pharmacy/Treatment Supplier's Special Administrati|

    give_per_time_unit_cd

    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)|

    give_quantitytiming_qt

    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|

    give_rate_amt

    The amount (number) of substance to be administered.

    |RXE^23^00332^Give Rate Amount| |RXG^15^00332^Give Rate Amount|

    max_give_amt

    The maximum ordered amount.

    |RXE^4^00319^Give Amount - Maximum| |RXG^6^00319^Give Amount - Maximum|

    min_give_amt

    The minimum order amount.

    |RXE^3^00318^Give Amount - Minimum| |RXG^5^00318^Give Amount - Minimum|

    needs_human_review_ind

    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|

    substitution_status_cd

    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|

    supplier_special_administration_instruction_cd

    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|

    Stewardship for: DRAFT HL7 Reference Information Model

    Subject Area: STW_C02_Control_Query

    Subject Area: STW_C03_Pt_admin_Finance

    Subject Area: STW_C04_Orders_observations

    Subject Area: STW_C09_Medical_records

    Subject Area: STW_C10_Inter_enterprise

    Subject Area: STW_C12_Patient_care

    Interested committee for: DRAFT HL7 Reference Information Model

    Subject Area: COI_C036_PAFM

    Subject Area: COI_C047_Orders_Observations

    Subject Area: COI_C09_Medical_records

    Subject Area: COI_C12_Patient_care

    DIM for: DRAFT HL7 Reference Information Model

    Subject Area: DIM_Control_Query

    Subject Area: DIM_Finance

    Subject Area: DIM_Medical_records

    Subject Area: DIM_Orders_observations

    Subject Area: DIM_Patient_administration

    Subject Area: DIM_Patient_care

    Subject Area: DIM_Patient_referral

    Subject Area: DIM_Scheduling