S&I Framework B Data Elements (Harm. Team) October 13, 2011

S&I Framework B Data Elements

(Harm. Team)

October 13, 2011

Admitting and Discharging Diagnoses

Name of Data Element Definition of Data Element ISO/HL7 Datatype Examples andGuidance Data Element Priority

Code LOINC Code B

Diagnosis Name

Type of medical condition the requires monitoring, diagnostic, therapeutic or educational action.

B

Patient Conditions Summary on patient admitted condition B

Problem Observation

A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need.

A Problem Observation is, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid "standalone" template instance in cases where a simple problem observation is to be sent.

B

Equipment


Code Equipment code set BDate Acquired BDate Disposed BID BQuantity BName Type of Equipment BOwner Responsible Party BStatus B

Family History


Code Family History LOINC BTitle B

Organizer

Contains table of information regarding a set of observations with a family member

E.g. can group a set of observations about the patient’s parents.

B

Administrative Gender Code sets for gender HL7 V3 E.g. F= Female, M= Male, UN = undifferntiated B

Deceased Narrative section for deceased family members B

Role Code detailing relationships of family members

E.g. DauAdopt= Adopted DaughterFTH = Father

B

Birth date Date of Birth of family members E.g. June 1, 1912 B

Observation Outlines name of disease or condition for family E.g. myocardial infarction,

tachycardia B

Problem Code Snomed CT E.g. 55561003 = Active, 7087005 = Intermittent B

Death ObservationClinical statement records whether the family member is deceased

E.g. “Dead” B

History of Present Illness

Name of Data Element Definition of Data Element ISO/HL7 Datatype Examples andGuidance

Data Element Priority

History of Present Illness

Narrative that describes history related to the reason for the encounter. It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.

E.g. “This patient was only recently discharged for a recurrent GI bleed as described below” B

Code LOINC Code set B

Immunization History



Immunizations

Narrative that includes current immunization status, and may contain the entire immunization history that is relevant to the period of time being summarized.

E.g. Vaccine, Date, StatusInfluenza Virus Vaccine, Dec 2004, Completed

B

Code LOINC Code set B

Date Detailed Date and Time of immunization B

Administration Route B

Refusal Reason Rationale for non compliance with immunizations B

Product Information Immunization Medication Information

E.G. Vaccine lot number and typeTetanus and diphtheria toxoids - preservative free B

Vaccine code CVX code system E.G. 54 = adenovirus vaccine, type 4, live, oralx

Invasive and Non-Invasive Procedures



Act Represents all other types of procedures dressing change B

Act/code Type of instruction “patient instruction" or in the case of an immunization: code="171044003"

B

Instructions Narrative Clincians entry of specific medical guidance Follow discharge instructions, as in

patient history report B

Observation act Procedures that result in new information about a patient but do not cause physical alteration

EEG B

Observation Entry Time of entry BObservation Status B

Observation Performer Name of clinician conducting observation B

Procedures act Procedures the alter that physical condition of a patient Splenectomy B

Procedure Location Address of clinical setting where procedure was conducted B

Represented Organization Name of Organization where procedure was performed B

Service Delivery Location Address of clinical setting where procedure was conducted B

Medical History


Code Corresponding code set B

Past Medical History

Narrative of Patient’s past medical history even if the observations are not relevant to the current procedure at hand

Patient has had recent issue with acne that does not seem to be related to any particular cause. Previous concerns of oral cancer was actually irritated gums as a result of mild food allergy. Patient had recent weight gain due to sedentary lifestyle and new job.

B

Medication HistoryName of Data Element Definition of Data Element ISO/HL7

DatatypeExamples and

GuidanceData Element

PriorityApproach Site code dynamic B

Current Active Medications List of current active medications for patient B

Drug Vehicle The vehicle for administering a medication. (e.g. saline, dextrose) B

Medication History List Entire medication history for patient B

Medication Activity

Reflections of what a clinician intends a patient to take or medications currently used by patients

B

Medication Activity Start Start time of current medication BMedication Activity Status INT or ENV Medication Route code dynamic B

Repeat Number

a. In "INT" (intent) mood, the repeat number defines the number of allowed administrations. b. In "EVN" (event) mood, the repeat number is the number of occurrences.

a. (INT) For example, a repeat number of "3" means that the substance can be administered up to 3 times.

b. (EVN) For example, a repeatNumber of

"3" in a substance administration event means that the current administration is the 3rd in a series

B

Medication History (contd.)Name of Data Element Definition of Data Element ISO/HL7 Datatype Examples and


Priority

Quantity

If the consumable code is a precoordinated unit dose (e.g. "metoprolol 25mg tablet") then Quantity is a unitless number that indicates the number of products given per administration (e.g. "2", meaning 2 x "metoprolol 25mg tablet").

Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g. is simply "metoprolol"), then Quantity must represent a physical quantity with @unit, e.g. "25" and "mg", specifying the amount of product given per administration.

B

Indication Rationale for an activity For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section.

B

Indication Code BMedication Supply Order Date B

Medication History (contd. 2)Name of Data Element Definition of Data Element ISO/HL7 Datatype Examples and


PriorityMedication Supply Order Repeat Number of allowed refills B

Medication Information Generic product name BMedication Information code B

Medication Manufacturer Medication Manufacturing Company B

Medication Dispenser Address

Address of Dispensing organization B

Medication Dispenser Assigned Name

Doctor who prescribed the medication B

Medication Dispenser Name of represented organization B

Patient Instructions Patient instructions for a medication activity or fill instructions

B

Precondition for Substance Administration Name

Criterion for administration that can be used to record that the medication is to be administered only when the associated criteria are met

Wheezing B

Operative Summary


Code LOINC Code

e.g. code 34870-6 = Plastic surgery

B

EventDefines the main procedure being carried out

e.g. Colonoscopy or an Appendectomy, being documented.

B

Time Date and time of medical procedure B

Clinician

Documents the names and type of clinicians who actually and principally carry out the medical procedure.

There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes.

B

Patient Instructions


Code Defines the type of instruction e.g. code="171044003"

represents immunization B

Narrative Provides explanation on patient instructions

e.g. “Follow discharge instructions as noted in clinical report”

B

Pending Tests and Procedure


Assigned Entity Clinician responsible for conducting procedures B

ContextDescription of image-guided intervention or imaging service

e.g. “Magnetic resonance angiography, lower abdomen; with contrast material”

B

Effective Time Date and time of scheduled test/procedure B

Status B

Physical Exam


Code B

General Status Narrative of patient state findings upon examination

e.g. “Alert and in good spirits, no acute distress.” OR could include sections as follows:“Mental Status”, “Psychiatric Findings”, “Chest, Physical Findings”

B

Reason for Consult Request


Code LOINC code set B

Setting Location e.g. ICU, outpatient, hospital B

Narrative Clinician rationale for consultation B

Author Assigned clinician B

Functional Code Hierarchy of physicians involved

e.g. Attending physician, anesthesiologist B

Review of Systems


Code Relevant Codeset B

Review of SystemsRelevant symptoms and functions as systematically gathered by the patient

e.g. “Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.”

B

Results


Result ID BResult Date BResult Type BResult Status BResult Interpretation BResult Value BResult Reference Range B

Social History


Code e.g. 229819007 = “Tobacco use and exposure” B

Observation Narrative outlining defining the patient’s occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.

e.g. Cigarette smoking, Pregnant since May 2011, B

Observation Duration Time of observed behavior e.g. Smoking since 1999 B

Surgical/Procedural History


Code BSurgical Date BSurgical Type BOperation Note B

Vital Signs


Author Clinician conducting the vital signs B

Code B

Effective Time

Clinically effective time of the measurement, which is most likely when the measurement was performed

B

Observation Narrative around the clinical observation B

Observation Code B

Result Type Type of Vital Sign administered B

Result Value List of Vital Sign Results B