s&i framework b data elements (harm. team) october 6, 2011

S&I Framework B Data Elements

(Harm. Team)

October 6, 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

Invasive and Non-Invasive Procedures

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

Data Element Priority

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

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

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

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

s&i framework b data elements (harm. team) october 6, 2011

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