RIM Derived and Influenced HL7 Standards
AbdulMalik Shakir
President and Chief Informatics Scientist
Your Healthcare Standards Conformance Partner
© 2014 All Rights ReservedSlide Number: 2
Health Information Integration Infrastructure
Solutions
Hi3 Solutions is a privately owned Health Information Technology vendor
headquartered in Los Angeles, California.
We provide health information technology products, education, and consulting
services that enable our clients to engage effectively in health information
exchange, health data integration, and health care quality measurement .
Our mission is to accelerate the adoption and application of standards-based
health information exchange as a mean’s of improving healthcare outcomes
and facilitating compliance with evidence-based best practices in healthcare.
© 2014 All Rights ReservedSlide Number: 3
Electronic Health Information Exchange
Pharmacies
Physicians
Testing OrganizationsLab/Images
Hospitals
Payors
Employers
County/Community Entities
Patients/ConsumersGovernmentMedicare/Medicaid
Lab results
Patient Data
Orders
Results
Images
Eligibility
Referral Process
Claim Status
Claims/Prescriptions
Referral Process
Claim/Status
Health Information
Insurance Updates
Eligibility
Medical Records
Enrollment
Mental Health
Family Planning
Medical Society
Public Health
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Instructor
• AbdulMalik Shakir, President and Chief Informatics Scientist for Hi3 Solutions.
• I have been an active HL7 member since 1991 and I’ve made significant contributions to the development and adoption of the HL7 standard.
• I am co-chair of the HL7 Modeling and Methodology work group, former member of the HL7 Board of Directors, and an active participant in many HL7 foundation and domain expert work groups.
• I am the author of the original RIM and provided oversight for its maintenance from inception through its first publication as an ANSI and then ISO standard.
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Session Overview
• This tutorial provides an introduction to the major HL7 RIM derived and RIM influenced standards. The student will also learn key aspects of the HL7 V3 Development Framework (HDF).
• Topics Covered:– HL7 Development Framework
– HDF Methodology
– HL7 V3 Development Artifacts
– Sample V3 Clients and Projects
• This tutorial will assist in preparation for the HL7 v3 Certification exam.
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HL7 Development Framework
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HDF Introduction
• The Health Level Seven Development Framework (HDF) defines the processes, policies, and artifacts associated with development of HL7 specifications and standards.
• The HL7 Development Framework (HDF):– Expands HL7’s modeled-based approach for standards
development beyond messaging to its other standards such as structured documents, context management, and standards related to electronic health records;
– Facilitates increased participation of HL7 members, subject matter experts, and implementers in the development of HL7 standards.
– Enables HL7 to remain the industry leader in model-driven development of comprehensive standards for application interoperability in the Health industry.
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HDF Background – Health Level Seven
• The mission of HL7 is to provide a comprehensive framework and related standards for the exchange, integration, storage, and retrieval of health information that support clinical practices and the management, delivery and evaluation of health services.
• HL7 began developing standards in 1987 with the publication of its messaging specification - the Application Protocol for Electronic Data Exchange in Healthcare Environments.
• In the years since its founding, HL7 has evolved beyond traditional messaging protocols to include clinical document architectures, medical logic modules, service component specifications, and standards, guidelines, and related services for the management of electronic health records.
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The Family of HL7 Standards
• Standardization of knowledge representation (Arden / GELLO) • Virtual Medical Record for Clinical Decision Support (vMR-CDS)• Specification of components for context management (CMA)• Standardization of clinical document structures (CDA)• Electronic Health Record System Functional Model (EHR-S)• Application protocol for electronic data exchange in healthcare
environments (messages)• Support for use of healthcare services in a Service Oriented
Architecture (SOA)• Fast Healthcare Interoperability Resources (FHIR)• Specification of robust vocabulary definitions for use in clinical
messages and documents• Work in the area of security, privacy, confidentiality, and
accountability
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HDF Background – HL7 V3 Methodology
• In 1992 HL7 made a fundamental shift in the method it uses to develop its specifications and standards.
• The new methodology, referred to as HL7 Version 3.0 (or V3), is a model-driven standards development methodology based upon object-oriented software development practices.
• In January 1996, the HL7 Technical Steering Committee adopted the model-driven approach and the Modeling and Methodology Technical Committee assumed primary responsibility for ongoing development of the V3 methodology.
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HL7 Message Development Framework
• The HL7 Message Development Framework (MDF) defines the HL7 V3 message development process.
• It identifies the phases, activities, and models used in the process of developing HL7 message specifications.
• The HL7 MDF was first published in 1997. It has undergone two major revisions since then; once in 1998 and again in 1999.
• The current version of the MDF (v3.3), published in December 1999, has not been maintained.
• The HDF is a replacement for and an extension to the HL7 Message Development Framework (MDF)
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HL7 V3 Methodology: What and How
Use Case Modeling
Interaction Modeling
Message Design
Information Modeling
RIM
Restrict
R-MIM
Serialize
HMD
Restrict
MessageType
Example
Storyboard
StoryboardExample
D-MIM
Derive
ApplicationRole
Sender Receiver
TriggerEvent
Triggers
Content
InteractionReferences
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HL7 V3 Design ModelsRIM
(1)Define aD-MIM
D-MIM
(2)Define aR-MIM
R-MIM
(3)Create
an HMD
HMD
RIMReference Information Model
D-MIMDomain Message Information Model
R-MIMRefined Message Information Model
HMDHierarchical Message Definition
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HL7 Development Framework
Methodology
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Seven Phases of the HDF Methodology
1. Project initiation
2. Requirements Documentation
3. Specification Modeling
4. Specification Documentation
5. Specification Approval
6. Specification Publication
7. Specification Profiling
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HDF Workflow DiagramInitiateProject
ProjectCharter
SpecifyRequirements
ReferenceModels
RequirementSpecification
Prepare SpecificationDesign Models
SpecificationDesign Models
PrepareSpecification
ApproveSpecification
ApprovedSpecification
PublishApproved
Specification
PublishedSpecification
Prepare SpecificationProfiles
SpecificationProfile
ConformanceStatement
Pre-ApprovalSpecification
The HDF workflow is not a waterfall methodology.Each phase builds upon the prior and may causeprior activities to be revisited and their deliverablesadjusted.
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Project initiationDuring project initiation the project is defined, a project plan is produced, and project approval is obtained. The primary deliverable produced during project initiation is the project charter.
ProjectInitiation
ProjectCharter
1. Define project scope, objectives, and intended deliverables
2. Identify project stakeholders, participants, and required resources
3. Document project assumptions, constraints, and risk
4. Prepare preliminary project plan and document inter-project dependencies
5. Obtain project approval and launch the project
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Requirements DocumentationDuring requirements documentation the problem domain is defined, a model of the domain is produced, and the problem domain model is harmonized with HL7 reference models. The primary deliverable produced during requirements documentation is the requirements specification.
RequirementsDocumentation
Requirements Specification
1. Document Business Process: Dynamic Behavior and Static Structure
2. Capture Process Flow: UML Activity Diagram
3. Capture Structure: Domain Analysis Model and Glossary
4. Capture Business Rules: Relationships, Triggers, and Constraints
5. Harmonize the Domain Analysis Model with HL7 Reference Models
ProjectCharter
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Specification ModelingDuring specification modeling reference models are constrained into design models through a process of iterative refinement driven by requirements specifications and following specification design rules, conventions, and guidelines. The primary deliverable produced during specification modeling is a set of specification design models.
SpecificationModeling
SpecificationDesign Models
1. Build design models of static information views
2. Construct design models of behavioral views
3. Define reusable design model components
4. Construct design models of collaboration and interaction
5. Harmonize design models with HL7 Reference Models
RequirementsSpecification
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Specification DocumentationDuring specification Documentation the specification design models are packaged into logical units, supplemented with explanatory text, and prepared for approval. The primary deliverable produced during specification documentation is a pre-approval specification.
SpecificationDocumentation
Pre-ApprovalSpecification
1. Organize design model elements into logical packages
2. Compose explanatory text, examples, and design rationale
3. Update design models and requirement specifications
4. Assemble a pre-approval specification package
5. Submit specification for approval
SpecificationDesign Models
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Specification ApprovalDuring specification approval the pre-approval specification is subjected to a series of approvals steps. The specific approval steps vary by kind of specification, level of approval, and realm of interest. The primary deliverable produced during specification approval is an approved specification.
SpecificationApproval
ApprovedSpecification
1. Obtain TSC and Board approval to ballot specification
2. Form a ballot pool and conduct specification ballot
3. Assess negative ballots and affirmative comments
4. Modify specification in response to ballot comments
5. Resolve negative ballot responses and if necessary reballot
Pre-ApprovalSpecification
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Specification PublicationDuring specification publication the approved specification is prepared for prepared for publication and distribution. The primary deliverable produced during specification publication is a published specification.
SpecificationPublication
PublishedSpecification
1. Obtain TSC and Board approval to publish specification
2. Prepare specification for publication
3. Submit publication to standards authorities (ANSI/ISO)
4. Render the specification in various forms of publication media
5. Post and distribute approved specifications
ApprovedSpecification
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Specification ProfilingDuring specification profiling specification models are further refined and specifications furthered constrained following the same set of design rules, conventions, and guidelines used in the development of the specification to produce a profile of the specification for use in a particular environment by a defined community of users. The primary deliverable produced during specification profiling is a set of specification profiles and conformance statements.
SpecificationProfiling
SpecificationProfiles and
ConformanceStatements
1. Identify community of uses for published specification
2. Further refine and constrain specification design models
3. Document exceptions, extensions, and annotations to specifications
4. Prepare and publish specification profile
5. Prepare and publish conformance statements
PublishedSpecification
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HDF Workflow DiagramInitiateProject
ProjectCharter
SpecifyRequirements
ReferenceModels
RequirementSpecification
Prepare SpecificationDesign Models
SpecificationDesign Models
PrepareSpecification
ApproveSpecification
ApprovedSpecification
PublishApproved
Specification
PublishedSpecification
Prepare SpecificationProfiles
SpecificationProfile
ConformanceStatement
Pre-ApprovalSpecification
The HDF workflow is not a waterfall methodology.Each phase builds upon the prior and may causeprior activities to be revisited and their deliverablesadjusted.
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HL7 Version 3.0 Development Artifacts
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HL7 v3.0 Development ArtifactsReference
InformationModel
ReferenceInformation
Model
DatatypeSpecification
DatatypeSpecification
VocabularySpecificationVocabulary
SpecificationReference
Models
InteractionModel
InteractionModel
DesignInformation
Model
DesignInformation
Model
CommonMessage Type
Model
CommonMessage Type
Model
DesignModels
HierarchicalMessage
Definition
HierarchicalMessage
Definition
MessageType
Definition
MessageType
Definition
ImplementationTechnology
Specification
ImplementationTechnology
Specification
Content Specifications
MessageProfile
Specification
MessageProfile
Specification
LocalizedMessage
Specification
LocalizedMessage
Specification
MessageConformanceStatements
MessageConformanceStatements
ImplementationProfiles
© 2014 All Rights ReservedSlide Number: 28
HL7 v3.0 Development Artifacts
ReferenceInformation
Model
ReferenceInformation
Model
DatatypeSpecification
DatatypeSpecification
VocabularySpecificationVocabulary
Specification
Reference Models
The HL7 Reference Information Model is the information model from which all other information models and message specifications are derived.
The HL7 Vocabulary Specification defines the set of all concepts that can be taken as valid values in an instance of a coded attribute or message element.
The HL7 Datatype Specification defines the structural format of the data carried in an attribute and influences the set of allowable values an attribute may assume.
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HL7 v3.0 Development Artifacts
InteractionModel
InteractionModel
DesignInformation
Model
DesignInformation
Model
CommonMessage Type
Model
CommonMessage Type
Model
Design Models
An Interaction Model is a specification of information exchanges within a particular domain as described in storyboards and storyboard examples.
A Domain Information Model is an information structure that represents the information content for a set of messages within a particular domain area.
A Common Message Type Model is a definition of a set of common message components that can be referenced in various message specifications.
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HL7 v3.0 Messaging Artifacts
HierarchicalMessage
Definition
HierarchicalMessage
Definition
MessageType
Definition
MessageType
Definition
ImplementationTechnology
Specification
ImplementationTechnology
Specification
Message Specifications
An Hierarchical Message Definition is a specification of message elements including a specification of their grouping, sequence, optionality, and cardinality.
A Message Type Definition is a specification of a collection of message elements and a set of rules for constructing a message instance.
An Implementation Technology Specification is a specification that describes how to construct HL7 messages using a specific implementation technology.
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HL7 v3.0 Development Artifacts
MessageProfile
Specification
MessageProfile
Specification
LocalizedMessage
Specification
LocalizedMessage
Specification
MessageConformance
Statement
MessageConformance
Statement
Implementation Profiles
A Localized Message Specification is a refinement of a HL7 message specification standard that is specified and balloted by an HL7 International Affiliate.
A Message Profile Specification is a description of a particular or desired implementation of an HL7 Message standard or Localized Message specification.
A Message Conformance Statement is a comparison of a particular messaging implementation and an HL7 message standard, localization, or profile.
© 2014 All Rights ReservedSlide Number: 32
HL7 V3 Message Design Models
RIM
Account
name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>
DeviceTask
parameterValue : LIST<ANY>
DiagnosticImage
subjectOrientationCode : CE
Diet
energyQuantity : PQcarbohydrateQuantity : PQ
FinancialContract
paymentTermsCode : CE
FinancialTransaction
amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL
InvoiceElement
modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL
ManagedParticipation
id : SET<II>statusCode : SET<CS>
Observation
value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>
PatientEncounter
preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE
Procedure
methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>
PublicHealthCase
detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE
SubstanceAdministration
routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE
Supply
quantity : PQexpectedUseTime : IVL<TS>
WorkingList
ownershipLevelCode : CE
Container
capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ
Device
manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS
LivingSubject
administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL
ManufacturedMaterial
lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>
Material
formCode : CENonPersonLivingSubject
strainText : EDgenderStatusCode : CE
Organization
addr : BAG<AD>standardIndustryClassCode : CE
Person
addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>
Place
mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST
Access
approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ
Employee
jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED
LicensedEntity
recertificationTime : TS
Patient
confidentialityCode : CEveryImportantPersonCode : CE
ActRelationship
typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL
Act
classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE
0..n
1
outboundRelationship
0..n
source1
0..n
1
inboundRelationship
0..n
target
1
LanguageCommunication
languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL
Participation
typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...
0..n
1
0..n
1
Entity
classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE
1
0..n
1
0..n
RoleLink
typeCode : CSeffectiveTime : IVL<TS>
Role
classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>
0..n
1
0..n
10..n0..1
playedRole0..n
player
0..1
0..n0..1
scopedRole
0..n
scoper
0..1
0..n
1
outboundLink 0..n
source1
0..n
1
inboundLink0..n
target1
HMD
Design Information Model
D-MIM
PatientIncidentclassCode*: <= ENCmoodCode*: <= EVNid: [1..*] (RegistNum)code: CV CNE [0..1] <= ExternallyDefinedActCodes (PatientType)statusCode: LIST<CS> CNE <= ActStatus (IDPHStatus)activityTime: TS (EDDate)
InjuryclassCode*: <= ACTmoodCode*: <= EVNactivityTime: TS (InjuryDate)
0..1 pertinentInjury
typeCode*: <= PERTpertinentInformation1
TraumaRegistryExport(IDPH_RM00001)
Data content of HL7messages used to exportdata from the IDPH TraumaRegistry.
PatientPersonclassCode*: <= PSNdeterminerCode*: <= INSTANCEname: PN [0..1] (*Name)existenceTime: (Age)administrativeGenderCode: CV CWE <= AdministrativeGender (GenderID)birthTime: (DateOfBirth)addr: AD [0..1] (AddressHome)raceCode: CV CWE [0..1] <= Race (RaceID)ethnicGroupCode: CV CWE [0..1] <= Ethnicity (EthnicID)
1..1 patientPatientPerson
1..1 providerTraumaParticipant
PatientclassCode*: <= PATid: II [0..1] (MedicaRecordNum)
TraumaParticipantclassCode*: <= ORGdeterminerCode*: <= INSTANCEid: [1..1] (HospitNum)code: CV CWE [0..1] <= EntityCodename: ON [0..1] (HospitName)statusCode: CS CNE [0..1] <= EntityStatus (ActiveFacili)addr: AD [0..1] (HospitCity)
1..1 patient
typeCode*: <= SBJsubject
InjuryLocationclassCode*: <= PLCdeterminerCode*: <= INSTANCEcode: CV CWE [0..1] <= EntityCode (InjuryPlaceID)addr: AD [0..1] (AddressScene)
0..1 playingInjuryLocation
RoleclassCode*: <= ROL
1..1 participant
typeCode*: <= LOC
location
InjuryRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ExternallyDefinedActCodespriorityCode: CV CWE [0..1] <= ActPriorityvalue: [0..1]
0..* pertinentInjuryRelatedObservation
typeCode*: <= PERTsequenceNumber: INT [0..1] (InjurySequen)
pertinentInformation
ProcedureclassCode*: <= PROCmoodCode*: <= EVNcode: CV CWE <= ActCode (ICDCodeID)activityTime: TS (ProcedDate)
0..* pertinentProcedure
typeCode*: <= PERTpertinentInformation7
0..1 medicalStaff
typeCode*: <= PRFperformer
MedicalStaffclassCode*: <= PROVid: II [0..1] (MedicalStaffID)
0..1 procedureLocation
typeCode*: <= LOClocation
ProcedureLocationclassCode*: <= SDLOCcode: <= RoleCode (ProcedLocateID)
PatientIncidentRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ActCodereasonCode: CV CWE [0..1] <= ActReasonvalue: ANY [0..1]
0..* pertinentPatientIncidentRelatedObservation
typeCode*: <= PERTpertinentInformation2
PatientTransferclassCode*: <= TRNSmoodCode*: <= EVNactivityTime: IVL<TS> (DischaDate to ArriveDate)reasonCode: CV CWE [0..1] <= TransferActReason (REASONTRANSFID)
1..1 arrivalPatientTransfer
typeCode*: <= ARRarrivedBy
0..* aRole
typeCode*: <= ORGorigin
0..1 playingTraumaParticipant
aRoleclassCode*: <= ROL
TransferRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: CV CWE <= ExternallyDefinedActCodesvalue: PQ [0..1]methodCode: CV CWE [0..1] <= ObservationMethod
1..* pertinentTransferRelatedObservationtypeCode*: <= PERT
pertinentInformation
1..1 transferVehicle
typeCode*: <= VIAvia
1..1 owningVehicleProvider
TransferVehicleclassCode*: <= OWNid: II [0..1] (VehiclNum)code: <= RoleCode (VehiclLevelID)
VehicleProviderclassCode*: <= ORGdeterminerCode*: <= INSTANCEid: II [0..1] (VehiclProvide)code: <= EntityCode (MaxVehiclLevelID)name: ON [0..1] (VehiclProvidName)
HospitalVisitclassCode*: <= ENCmoodCode*: <= EVNcode: CV CWE <= ActCode (AdmitServicID)activityTime: TS (DischaDate)dischargeDispositionCode: CV CWE [0..1] <= EncounterDischargeDisposition
1..1 pertinentHospitalVisit
typeCode*: <= PERTpertinentInformation5
HospitalVisitRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: CV CWE <= ExternallyDefinedActCodesvalue: [0..1]
0..* pertinentHospitalVisitRelatedObservation
typeCode*: <= PERT
pertinentInformation
1..1 admittingProvider
typeCode*: <= ADMadmitter
0..1 healthCareMedicalStaffPerson
AdmittingProviderclassCode*: <= PROVid: II [0..1] (ADMITMEDICASTAFFID)code: CV CWE <= RoleCode (StaffTypeID)
0..* hospitalVisitPhysician
typeCode*: <= RESPtime: TS
responsibleParty
0..1 healthCareMedicalStaffPerson
HospitalVisitPhysicianclassCode*: <= PROVid: II [0..1]code: CV CWE <= RoleCode (StaffTypeID)
MedicalStaffPersonclassCode*: <= PSNdeterminerCode*: <= INSTANCEname: PN [0..1] (MedicaStaffName)
0..1 licensedEntity
typeCode*: <= DSTdestination
0..1 subjectChoice
LicensedEntityclassCode*: <= LICid: II [0..1]
Choice
FacilityclassCode*: <= ORGdeterminerCode*: <= INSTANCEid:code*: CS CNE <= EntityCode "FAC"name:
HospitalclassCode*: <= ORGdeterminerCode*: <= INSTANCEid:code*: CS CNE <= EntityCode "HOSP"name:
EmergencyDepartmentEncounterclassCode*: <= ENCmoodCode*: <= EVNactivityTime: IVL<TS>dischargeDispositionCode: CV CWE <= EncounterDischargeDisposition
0..1 pertinentEmergencyDepartmentEncounter
typeCode*: <= PERT
pertinentInformation3
EmergencyDepartmentRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: CV CWE <= ExternallyDefinedActCodestext:activityTime: TSreasonCode: <= ActReasonvalue: [0..1]methodCode: CV CWE [0..1] <= ObservationMethodtargetSiteCode: CV CWE [0..1] <= HumanActSite
0..* pertinentEmergencyDepartmentRelatedObservation
typeCode*: <= PERTpertinentInformation
0..* emergencyDepartmentPhysician
typeCode*: <= PRFperformer
0..1 healthCareMedicalStaffPerson EmergencyDepartmentPhysicianclassCode*: <= PROVid: II [0..1]code: CE CWE [0..1] <= RoleCode (StaffTypeID)
PreHospitalEncounterclassCode*: <= ENCmoodCode*: <= EVNid: II [0..1] (crashNum)activityTime: IVL<TS>
0..1 priorPreHospitalEncounter
typeCode*: <= PREV
predecessor
PreHosptialRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ExternallyDefinedActCodesvalue: ANY [0..1]
0..* pertinentPreHosptialRelatedObservation
typeCode*: <= PERTpertinentInformation
1..1 preHospitalVehicle
typeCode*: <= ParticipationTypeparticipant
1..1 owningVehicleProvider
PreHospitalVehicleclassCode*: <= OWNid: II [0..1] (VehiclNum)code: <= RoleCode (VehiclLevelID)
0..* emergencyDepartmentPhysicianActtypeCode*: <= COMP
component
EmergencyDepartmentPhysicianActclassCode*: <= ACTmoodCode*: <= EVNcode: CS CNE [0..1] <= ExternallyDefinedActCodesactivityTime*: TS [0..1]
component
0..* patientIncidentRelatedObservation
typeCode*: <= COMP
VehicleProvider
MedicalStaffPerson
TraumaParticipant
R-MIM
PatientIncidentclassCode*: <= ENCmoodCode*: <= EVNid: [1..*] (RegistNum)code: CV CNE <= ExternallyDefinedActCodes (PatientType)statusCode: LIST<CS> CNE <= ActStatus (IDPHStatus)activityTime: TS (EDDate)
InjuryclassCode*: <= ACTmoodCode*: <= EVNactivityTime: TS (InjuryDate)
0..1 pertinentInjury
typeCode*: <= PERTpertinentInformation1
PatientPersonclassCode*: <= PSNdeterminerCode*: <= INSTANCEname: PN [0..1] (*Name)existenceTime: (Age)administrativeGenderCode: CV CWE <= AdministrativeGender (GenderID)birthTime: (DateOfBirth)addr: AD [0..1] (AddressHome)raceCode: CV CWE [0..1] <= Race (RaceID)ethnicGroupCode: CV CWE [0..1] <= Ethnicity (EthnicID)
1..1 patientPatientPerson
1..1 providerTraumaParticipant
PatientclassCode*: <= PATid: II [0..1] (MedicaRecordNum)
TraumaParticipantclassCode*: <= ORGdeterminerCode*: <= INSTANCEid: [1..1] (HospitNum)code: CV CWE [0..1] <= EntityCodename: ON [0..1] (HospitName)statusCode: CS CNE [0..1] <= EntityStatus (ActiveFacili)addr: AD [0..1] (HospitCity)
1..1 patient
typeCode*: <= SBJsubject
InjuryLocationclassCode*: <= PLCdeterminerCode*: <= INSTANCEcode: CV CWE [0..1] <= EntityCode (InjuryPlaceID)addr: AD [0..1] (AddressScene)
0..1 playingInjuryLocation
RoleclassCode*: <= ROL
1..1 participant
typeCode*: <= LOC
location
InjuryRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ExternallyDefinedActCodespriorityCode: CV CWE [0..1] <= ActPriorityvalue: [0..1]
0..* pertinentInjuryRelatedObservation
typeCode*: <= PERTsequenceNumber: INT [0..1] (InjurySequen)
pertinentInformation
PatientIncidentRelatedObservationclassCode*: <= OBSmoodCode*: <= EVNcode: <= ActCodereasonCode: CV CWE [0..1] <= ActReasonvalue: ANY [0..1]
0..* pertinentPatientIncidentRelatedObservation
typeCode*: <= PERT
pertinentInformation2
component
0..* patientIncidentRelatedObservation
typeCode*: <= COMP
© 2014 All Rights ReservedSlide Number: 33
Design Information Model Description
• Domain Message Information Models (D-MIMs) and Refined Message Information Models (R-MIMs) are types of Design Information Models.
• Design information models are composed of class clones that are a restricted subset of the HL7 RIM.
• Class clones contain a subset of the attributes and relationships that are defined for the RIM class upon which the clone is based.
• Multiple class clones based upon the same RIM class may be included in a design information model.
• Each class clone in a design information model is assigned a unique name.
© 2014 All Rights ReservedSlide Number: 34
Sample R-MIM Design Information Modelcomponent1 / componentOf3
0..* observationOrder1
0..* observationOrder2 *
typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"sequenceNumber:priorityNumber:pauseQuantity:splitCode:joinCode:seperatableInd: [1..1] "true"
0..* pertinentObservationSupporting
typeCode*: <= PERTcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"
pertinentInformation
0..* substanceAdministrationStep *
component2typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"sequenceNumber*: [1..1]priorityNumber:pauseQuantity:splitCode:joinCode:seperatableInd*: [1..1] "false"
SubstanceAdministrationStepclassCode*: <= SBADMmoodCode*: <= x_ActMoodOrdPrmsEvnid*: II [1..1]code*: CE CWE <= SubstanceAdministrationActCodetext*:statusCode*: CS CNE [0..1]effectiveTime*: IVL<TS>routeCode: <= RouteOfAdministrationdoseQuantity: PQrateQuantity: PQ
ObservationOrderclassCode*: <= OBSmoodCode*: <= ORDid*: II [1..1]code: CE CWE <= ObservationType (e.g. LOINC code)negationInd: [1..1] "false"derivationExpr:text:statusCode*: CS CNE [1..1] <= ActStatus "active"effectiveTime: ("physiologically relevant time" aimed for)activityTime: IVL<TS>priorityCode: CE CWE [0..1] <= ActPriority "R"confidentialityCode*: [1..*] <= Confidentiality "N"repeatNumber:interruptibleInd: "true"independentInd: "true"methodCode: <= ObservationMethodtargetSiteCode: <= ActSite
AccessionclassCode*: <= ACSNmoodCode*: <= EVNid*: II [1..1]
CMET: (ENC) A_Encounter
[universal](COCT_MT010000)
CMET: (ASSIGNED) R_Assigned
[universal](COCT_MT090000)
0..1 roleName
CMET: (PAT) R_Patient[universal]
(COCT_MT050000)
0..1 roleName
CMET: (CONS) A_Consent[universal]
(COCT_MT470000)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
0..1 roleName
0..* participant
typeCode*: <= CSMcontextControlCode*: [1..1] <= ContextControlNonPropagating "ON"
consumable
0..1 assignedEntity
dataEnterertypeCode*: <= ENTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"noteText: STtime: TS (time entered into)modeCode*: [1..1] <= "ELECTRONIC"
0..1 assignedEntity
notificationContacttypeCode*: <= NOTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"
0..1 patient *
recordTargettypeCode*: <= RCTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"
0..* accession
typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlPropagating "OP"contextConductionInd*: [1..1] "false"
componentOf2
Note:For Advanced Beneficiary Noticesor whenconsents are required fortesting (e.g., HIV related tests.)
Note:This is the general almost completely unconstrainedActRelationship. Its use includes composition (COMP),occurrences (OCCR), master file references (INST),fulfillment (FLFS) and replacement (RPLC) as well asnormal ranges (REFV), decision ranges (COND) andgoals. In the DMIM this is left unconstrained, in theRMIMs these might be more constrained.
0..* consent
typeCode*: <= SUBJcontextControlCode*: [1..1] <= ContextControlPropagating "OP"contextConductionInd*: [1..1] "false"
subjectOf
0..* specimen *
subjecttypeCode*: <= SBJcontextControlCode*: [1..1] <= ContextControlPropagating "OP"
Note:For clinical observations that are made directly on the patientinstead of on some specimen.
Note:The author of an ORDer is commonlyknow as the "placer", the author of anordered promise or event is commonlyknown as the "filler". The author ownshis Act, meaning that direct statuscanges on this act can only be issuedby the Author.
1..1 manufacturedProduct *
typeCode*: <= CSM
consumable
0..1 encounter *
componentOf1typeCode*: <= COMPcontextControlCode*: [1..1] <= ContextControlPropagating "OP"contextConductionInd*: [1..1] "false"
1..1 agent *
typeCode*: <= AUTauthor
Note:Includes both, theindividual and theprovider organization.
0..* assignedEntity
typeCode*: <= VRFcontextControlCode*: [1..1] <= ContextControl "OP"noteText: STtime*: TS [1..1] (time of signature)modeCode*: [1..1] <= ParticipationModesignatureCode*: [1..1] <= ParticipationSignaturesignatureText:
verifier
1..1 assignedEntity *
authortypeCode*: <= AUTcontextControlCode*: [1..1] <= ContextControlPropagating "OP"noteText: STtime*: TS [1..1] (time of signature)modeCode*: CE CNE [1..1] <= ParticipationModesignatureCode*: CS CNE [1..1]signatureText:
Note:Includes bothpatient and theinstitution.
CMET: (SPEC) R_Specimen
[universal](COCT_MT080000)
CMET: (OBS) A_ObservationSupporting
[universal](COCT_MT120200)
0..1 observationDefinition *
typeCode*: <= INSTcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "true"
definition
replacementOf
0..* priorObservation
typeCode*: <= RPLCcontextControlCode*: [1..1] <= ContextControlNonPropagating "ON"contextConductionInd*: [1..1] "true"
Note:For orders: the designated performer, if knownand desired at time of ordering. For intents, thepromises and events, the "filler." For individual sub-tasks, used for the technician, etc.
0..* orderOptions
controlVariabletypeCode*: <= CTRLVcontextControlCode*: [1..1] <= ContextControlNonPropagating "AN"contextConductionInd*: [1..1] "false"
CMET: (ACT) A_OrderOptions
[universal](COCT_MT210000)
0..* assignedEntity *
performertypeCode*: <= PRFcontextControlCode*: [1..1] <= ContextControlPropagating "OP"
ObservationDefinitionclassCode*: <= OBSmoodCode*: <= DEFid: II [1..1]
Note:Identifies the "master"or "service catalog"entry of theobservation servicebeing performed. Usethis alone or in additionto an observationcode to specify whatis being observed orwhat is to be observed.
1..1 manufacturedDrug *
0..1 manufacturerOrganization
ManufacturedProduct1classCode*: <= MANU
CMET: (ROL) R_Reagent[universal]
(COCT_MT250000)
0..*
OrganizationclassCode*: <= ORGdeterminerCode*: <= INSTANCEname*: ON [1..1]
DrugclassCode*: <= MMATdeterminerCode*: <= INSTANCEcode*: [1..1] <= DrugEntity (Drug code)quantity:desc:
Laboratory Observation Order(POLB_RM002100)
Common entry point for laboratory ordercommunication. This includes single one-timeorders as well as recurring orders. This isused for recurring orders only if the fillersplits recurring orders into their occurrences.
© 2014 All Rights ReservedSlide Number: 35
Design Information Model Diagram
SubstanceAdministrationStepclassCode*: <= SBADMmoodCode*: <= x_ActMoodOrdPrmsEvnid*: II [1..1]code*: CE CWE <= SubstanceAdministrationActCodetext*:statusCode*: CS CNE [0..1]effectiveTime*: IVL<TS>routeCode: <= RouteOfAdministrationdoseQuantity: PQrateQuantity: PQ
1..1 manufacturedProduct *
typeCode*: <= CSM
consumable
1..1 manufacturedDrug *
0..1 manufacturerOrganization
ManufacturedProduct1classCode*: <= MANU
OrganizationclassCode*: <= ORGdeterminerCode*: <= INSTANCEname*: ON [1..1]
DrugclassCode*: <= MMATdeterminerCode*: <= INSTANCEcode*: [1..1] <= DrugEntity (Drug code)quantity:desc:
• A Design Information Model diagrams used a variety of visual tools to document the design.
• Entities, Roles, and Acts are represented by rectangular shapes colored Green, Yellow, and Red respectively.
• Participations, Role Links, and Act Relationships are represented by arrow shapes colored blue, gold, and pink respectively.
• Bold font is used to denote mandatory attributes.
© 2014 All Rights ReservedSlide Number: 36
HL7 V3 Modeling Tools
© 2014 All Rights ReservedSlide Number: 37
HL7 V3 Modeling Tools
RationalRose
RationalRose
ReferenceModel
Repository
RoseTreeRoseTree
R-MIMDesigner
R-MIMDesigner
SchemaGenerator
SchemaGenerator
RIM RIM
R-MIMRIMR-MIM
HMD HMD
XSD
© 2014 All Rights ReservedSlide Number: 38
HL7 Version 3.0 Hierarchical Message
Definition
An Hierarchical Message Definition is a specification of message elements including a specification of their grouping, sequence, optionality, and cardinality.
© 2014 All Rights ReservedSlide Number: 39
Hierarchical Message Definition
© 2014 All Rights ReservedSlide Number: 40
HMD Components
Info
rmat
ion
Mo
del
Map
pin
g
Mes
sag
e E
lem
ent
Sp
ecif
icat
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s
Co
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nst
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Mes
sag
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Sp
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(S)
© 2014 All Rights ReservedSlide Number: 41
HMD Components
Map
pin
g t
o t
he
Info
rmat
ion
Mo
del
Mes
sag
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lem
ent
Sp
ecif
icat
ion
s
Co
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Co
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rain
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Mes
sag
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Sp
ecif
icat
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(S)
© 2014 All Rights ReservedSlide Number: 42
HL7 XML Schema Generator
HL7 Vocabulary Specification
HL7 Data Type Specification
HL7 XML Schema
Generator
Hierarchical MessageDefinition
XML SchemaSpecification
© 2014 All Rights ReservedSlide Number: 43
Sample HL7 Constrained Information Model
A_AbnormalityAssessment(COCT_RM420000UV)
Description: assessment of clinical findings, including lab test results,for indications of the presence and severity of abnormal conditions
AbnormalityAssessment
classCode*: = "OBS"moodCode*: = "EVN"code*: CD CWE [1..1] <= V:ObservationType ("ADVERSE_REACTION")statusCode*: CS CNE [1..1] <= V:ActStatusAbortedCancelledCompletedactivityTime*: TS.DATETIME [1..1]value: CD CWE [0..1] <= V:AbnormalityAssessmentValuemethodCode: SET<CE> CWE [0..*] <= V:AbnormalityAssessmentMethod
1..* assessmentOutcome *
typeCode*: = "OUTC"contextConductionInd*: BL [1..1] ="true"
outcome
AssessmentException
classCode*: = "OBS"moodCode*: = "EVN"code*: CD CWE [1..1] <= V:ObservationType ("ASSERTION")value*: SC CWE [1..1] <= V:AssessmentExceptionValue
AbnormalityGrade
classCode*: = "OBS"moodCode*: = "EVN"code*: CD CWE [1..1] <= V:ObservationType ("SEV")uncertaintyCode: CE CNE [0..1] <= V:ActUncertaintyvalue*: CD CWE [1..1] <= V:AbnormalityGradeValue
AssessmentOutcome
0..* assessmentOutcomeAnnotation
typeCode*: = "APND"contextConductionInd*: BL [1..1] ="true"
appendageOf
AssessmentOutcomeAnnotation
classCode*: = "OBS"moodCode*: = "EVN"code*: CD CWE [1..1] <= V:ObservationType ("ASSERTION")value*: SC CWE [1..1] <= V:AssessmentOutcomeAnnotationValue
© 2014 All Rights ReservedSlide Number: 44
Example Schema Specification
© 2014 All Rights ReservedSlide Number: 45
Core Schema
OurSchema
InfrastructureRoot.XSD
Datatype.XSD
Datatype-base.XSD
Voc.XSD
Include Include
Include Include Include
Include
Core Schema
• Our generated schema is used in conjunction with core schema specifications provided by HL7.
• The core schema specifications include infrastructure root, datatype base, datatype, and vocabulary.
• The core schema specification include no domain content. They are present only to facilitate interpretation of datatypes and validation of structural vocabulary.
© 2014 All Rights ReservedSlide Number: 46
HL7 V3 Message Implementation Technology
HL7-ConformantApplication
Data
HL7MessageCreation
HL7-ConformantApplication
HL7MessageParsing Data
MessageInstance
XML SchemaSpecification
Hierarchical MessageDefinition
© 2014 All Rights ReservedSlide Number: 47
Questions / Discussion
© 2014 All Rights ReservedSlide Number: 48
The Family of HL7 Standards
• Standardization of knowledge representation (Arden / GELLO) • Virtual Medical Record for Clinical Decision Support (vMR-CDS)• Specification of components for context management (CMA)• Standardization of clinical document structures (CDA)• Electronic Health Record System Functional Model (EHR-S)• Application protocol for electronic data exchange in healthcare
environments (messages)• Support for use of healthcare services in a Service Oriented
Architecture (SOA)• Fast Healthcare Interoperability Resources (FHIR)• Specification of robust vocabulary definitions for use in clinical
messages and documents• Work in the area of security, privacy, confidentiality, and
accountability
© 2014 All Rights ReservedSlide Number: 49
RIM Derived and Influenced HL7 Standards
• Standardization of knowledge representation (Arden / GELLO) Virtual Medical Record for Clinical Decision Support (vMR-CDS)• Specification of components for context management (CMA) Standardization of clinical document structures (CDA)• Electronic Health Record System Functional Model (EHR-S) Application protocol for electronic data exchange in healthcare
environments (messages)• Support for use of healthcare services in a Service Oriented
Architecture (SOA) Fast Healthcare Interoperability Resources (FHIR)• Specification of robust vocabulary definitions for use in clinical
messages and documents• Work in the area of security, privacy, confidentiality, and
accountability
© 2014 All Rights ReservedSlide Number: 50
Sample HL7 V3 Clients and Projects
Clinical Trial Registration and Results
Message Specification
Clinical Trial Registration and Results Message Specification
UMTS Project Consolidated Dictionary and IHE Content Profile
© 2014 All Rights ReservedSlide Number: 51
Clinical Trial Registration and Results Message Specification
© 2014 All Rights ReservedSlide Number: 52
CTRR Development Artifacts
© 2014 All Rights ReservedSlide Number: 53
Document Identifiers and Keywords
Planned Activities, Study Arms, and
References
Study Outcome Measures and Objectives
Study Participants
Regulatory Authorities, Application Submissions
and Authorizations
Target Research Products
(devices and substances)
Study Protocol Document, Study
Description, Features, and Overall Status
Study Sites and Study Site Recruitment
Activities
Study Enrollment
Stratification and Targets
© 2014 All Rights ReservedSlide Number: 54
RMIM to XSD
© 2014 All Rights ReservedSlide Number: 55
Traversing the CTRR RMIM
Entry Point
© 2014 All Rights ReservedSlide Number: 56
HMD – the RMIM serialized
© 2014 All Rights ReservedSlide Number: 57
Study Protocol Document XSD
© 2014 All Rights ReservedSlide Number: 58
Subject XSD
© 2014 All Rights ReservedSlide Number: 59
Clinical Trial Intent XSD
© 2014 All Rights ReservedSlide Number: 60
National Trauma Registry Submission CDA Document Specification
© 2014 All Rights ReservedSlide Number: 61
Clinical Document Architecture (CDA)
• The HL7 Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange.
• A clinical document contains observations and services and has the following characteristics:– Persistence – A clinical document continues to exist in an unaltered
state, for a time period defined by local and regulatory requirements.– Stewardship – A clinical document is maintained by an organization
entrusted with its care. – Potential for authentication - A clinical document is an assemblage of
information that is intended to be legally authenticated.– Context - A clinical document establishes the default context for its
contents.– Wholeness - Authentication of a clinical document applies to the whole
and does not apply to portions of the document without the full context of the document.
– Human readability – A clinical document is human readable.
© 2014 All Rights ReservedSlide Number: 62
Clinical Document Architecture RMIM
Clinical Document
Participating Entities
Structured Document Sections Section Entries
© 2014 All Rights ReservedSlide Number: 63
NTDB CDA RMIM Subset
ClinicalDocumentPatient
Organization
DocumentSection SectionEntry
Act Observ ation Encounter Procedure Organizer
EntryRelationship
1..*
0..1
0..*
+target 1
0..*
+source 1
+clinicalStatement
0..*
+nested0..*
+nesting0..1
1..*
1
+informer
0..*
communicates
1
+recordTarget
1..*
isSubjectOf
1
© 2014 All Rights ReservedSlide Number: 64
From Data Dict. to CDA Impl. Guide
© 2014 All Rights ReservedSlide Number: 65
Scope
© 2014 All Rights ReservedSlide Number: 66
Implementation Guide Development
© 2014 All Rights ReservedSlide Number: 67
DAM: a UML representation of dictionary elements
PreHospitalEcounter
- arrivalDateTime :TS [0..1]- departureDateTime :TS [0..1]- dispatchDateTime :TS [0..1]+ preHospitalTransportationMethodCode :TransportationMethod [0..*]
PreHospitalNerv ousSystemObserv ation
+ glasgowComaEyeResponseValue :INT+ glasgowComaMotorResponseValue :INT+ glasgowComaScoreValue :INT+ glasgowComaVerbalResponseCode :INT
PreHospitalCirculatorySystemObserv ation
+ heartRateAmount :PQ+ systolicBloodPressureAmount :PQ
PreHospitalRespiratorySystemObserv ation
+ arterialOxygenSaturationAmount :PQ+ respiratoryRateAmount :PQ
2.0 Submission::RegistrySubmissionTransaction
0..1 0..1
0..1
0..1
© 2014 All Rights ReservedSlide Number: 68
Organization of DAM Classes
2.0 Submission
+ RegistrySubmissionTransaction
1.0 Patients
+ Patient
3.0 Injury Ev ents
+ InjuryEvent
+ InjurySeverityObservation
4.0 PreHospital Encounters
+ PreHospitalCirculatorySystemObservation
+ PreHospitalEcounter
+ PreHospitalNervousSystemObservation
+ PreHospitalRespiratorySystemObservation
5.0 Hospital Care Episodes
+ HospitalCareEpisode
+ HospitalCirculatorySystemObservation
+ HospitalNervousSystemObservation
+ HospitalPhysiologicalObservation
+ HospitalRespiratorySystemObservation
+ 5.1 Emergency Hospital Encounters
+ 5.2 InpatientHospitalEncounters
© 2014 All Rights ReservedSlide Number: 69
Dictionary to DAMElement ID NTDB Dictionary Element DAM Package DAM Class DAM Attribute
D_01 D_01: PATIENT’S HOME ZIP CODE 2.0 Patients Patient postalAddressD_02 D_02: PATIENT’S HOME COUNTRY 2.0 Patients Patient postalAddressD_03 D_03: PATIENT’S HOME STATE 2.0 Patients Patient postalAddressD_04 D_04: PATIENT’S HOME COUNTY 2.0 Patients Patient postalAddressD_05 D_05: PATIENT’S HOME CITY 2.0 Patients Patient postalAddressD_06 D_06: ALTERNATE HOME RESIDENCE 2.0 Patients Patient residenceStatusCodeD_07 D_07: DATE OF BIRTH 2.0 Patients Patient birthDateD_08 D_08: AGE 2.0 Patients Patient eventRelatedAgeQuantityD_09 D_09: AGE UNITS 2.0 Patients Patient eventRelatedAgeQuantityD_10 D_10: RACE 2.0 Patients Patient raceCodeD_11 D_11: ETHNICITY 2.0 Patients Patient ethnicCodeD_12 D_12: SEX 2.0 Patients Patient genderCodeDG_01 DG_01: CO-MORBID CONDITIONS 5.0 Hospital Care Episodes HospitalCareEpisode coMorbidConditionCodeDG_02 DG_02: ICD-9 INJURY DIAGNOSES 5.0 Hospital Care Episodes HospitalCareEpisode injuryDiagnosisCodeDG_03 DG_03: ICD-10 INJURY DIAGNOSES 5.0 Hospital Care Episodes HospitalCareEpisode injuryDiagnosisCodeED_01 ED_01: ED/HOSPITAL ARRIVAL DATE 5.0 Hospital Care Episodes HospitalCareEpisode arrivalDateTimeED_02 ED_02: ED/HOSPITAL ARRIVAL TIME 5.0 Hospital Care Episodes HospitalCareEpisode arrivalDateTimeED_03 ED_03: INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE 5.0 Hospital Care Episodes HospitalCirculatorySystemObservation systolicBloodPressureAmountED_043 ED_043: INITIAL ED/HOSPITAL PULSE RATE 5.0 Hospital Care Episodes HospitalCirculatorySystemObservation heartRateAmountED_05 ED_05: INITIAL ED/HOSPITAL TEMPERATURE 5.0 Hospital Care Episodes HospitalPhysiologicalObservation temperatureAmountED_06 ED_06: INITIAL ED/HOSPITAL RESPIRATORY RATE 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation respiratoryRateAmountED_07 ED_07: INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation respiratoryAssistanceIndicatorED_08 ED_08: INITIAL ED/HOSPITAL OXYGEN SATURATION 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation arterialOxygenSaturationAmountED_09 ED_09: INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN 5.0 Hospital Care Episodes HospitalRespiratorySystemObservation supplementalOxygenIndicator
© 2014 All Rights ReservedSlide Number: 70
CIM: a CDA influenced UML representation of dictionary elements
Domain AnalysisModel
2
CDA RMIM
ConstrainedInformation Model
ArterialOxygenSaturationObserv ation
+ code :CD = ObservationType- value :PQ
::RespiratorySystemObservation+ classCode :CS = "OBS"+ moodCode :CS = "EVN"
RespiratoryRateObserv ation
+ code :CD = ObservationType- value :PQ
::RespiratorySystemObservation+ classCode :CS = "OBS"+ moodCode :CS = "EVN"
RespiratorySystemObserv ation
+ classCode :CS = "OBS"+ moodCode :CS = "EVN"
PreHospitalEncounterDetail::PreHospitalEncounter
RespiratorySystemEntryRelationship
+ typeCode :CS = x_ActRelationsh...+ contextConductionInd :BL = "true"
0..*
1
© 2014 All Rights ReservedSlide Number: 71
InjuryEv entSection
+ InjuryEventSection
+ StructuredBodyInjuryEventComponent
+ InjuryEventDetai lEntry
(from TraumaRegistrySubmissionDocument)
TraumaRegistrySubmissionDocument
+ HealthcareFacil i ty
+ RegistryParticipant
+ StructuredBodyComponent
+ StucturedBody
+ Submitter
+ TraumaRegistrySubmissionDocument
+ Patient
+ InjuryEventSection
+ PreHospital Encounter Section
+ Hospital Care Episode Section
+ EntryPoint
Patient
+ RecordTarget
+ Patient
+ PatientRole
+ PatientDetai lSection
(from TraumaRegistrySubmissionDocument)
PreHospital Encounter Section
+ PreHospitalEncounterSection
+ StructoredBodyPreHospitalEncounterComponent
+ PreHospitalEncounterDetail
(from TraumaRegistrySubmissionDocument)
Hospital Care Episode Section
+ HospitalCareEpisodeSection
+ StructuredBodyHospitalCareEpisodeComponent
+ HospitalCareEpisodeActivityDetai l
(from TraumaRegistrySubmissionDocument)
Organization of CIM Classes
© 2014 All Rights ReservedSlide Number: 72
DAM to CIM
DAM Class DAM Attribute CIM Class CIM Attribute
Patient birthDate Patient birthTimePatient ethnicCode Patient ethnicGroupCodePatient eventRelatedAgeQuantity PatientAgeObservation valuePatient genderCode Patient administrativeGenderCodePatient industryCode PatientIndustryObservation valuePatient occupationCode PatientOccupationObservation valuePatient postalAddress PatientRole addrPatient raceCode Patient raceCodePatient residenceStatusCode PatientResidenceStatusObservation valueInjuryEvent abbreviatedInjuryCode AbreviatedInjuryObservation valueInjuryEvent airbagDeploymentCode AirbagDeploymentObservation valueInjuryEvent bodyInjuryRegionCode BodyInjuryObservation valueInjuryEvent injurySeverityScoreValue SeverityScoreObservation valueInjuryEvent locationTypeCode LocationTypeObservation valueInjuryEvent occurenceDateTime InjuryEventAct effectiveTimeInjuryEvent postalAddress PostalAddressObservation valueInjuryEvent primaryInjuryCauseCode PrimaryInjuryCauseObservation valueInjuryEvent safetyEquipmentUsedCode SafetyEquipmentUsedObservation valueInjuryEvent supplementalInjuryCauseCode SupplementalInjuryCauseObservation valueInjuryEvent workRelatedEventInd WorkRelatedObservation valuePreHospitalCirculatorySystemObservation heartRateAmount HeartRateObservation valuePreHospitalCirculatorySystemObservation systolicBloodPressureAmount SystolicBloodPressureObservation valuePreHospitalEncounter arrivalDateTime PreHospitalEncounter effectiveTimePreHospitalEncounter departureDateTime PreHospitalEncounter effectiveTime
© 2014 All Rights ReservedSlide Number: 73
IG: Dictionary elements represented as templated CDA constraints
3
CDA RMIM
ConstrainedInformation Model
NTDBImplementation Guide
EMSImplementation Guide
© 2014 All Rights ReservedSlide Number: 74
Organization of IG Templates
© 2014 All Rights ReservedSlide Number: 75
Organization of IG Templates
StucturedBody
+ classCode :CS = "DOCBODY"+ moodCode :CS = "EVN"
StructuredBodyComponent
+ typeCode :CS = "COMP"+ contextConductionInd :BL = "true"
TraumaRegistrySubmissionDocument
+ classCode :CS = "DOCCLIN"+ moodCode :CS = "EVN"+ id :II+ code :CE = DocumentType- effectiveTime :TS
PatientDetailSection::PatientDetailSection
Patient::PatientRole RegistryParticipant
+ classCode :CS = "ASSIGNED"
Submitter
+ typeCode :CS = "INF"+ contextControlCode :CS = "OP"
HealthcareFacility
+ classCode :CS = "ORG"+ determinerCode :CS = "INSTANCE"- id :II
EntryPoint
Patient
+ RecordTarget
+ Patient
+ PatientRole
+ PatientDetailSection
PatientDetailSection
+ PatientDetailSection
+ StucturedBodyPatientDetailComponent
+ PatientDemographicObservation
+ PatientEmploymentObservation
(from Patient)
InjuryEv entSection::InjuryEv entSection PreHospital Encounter Section::PreHospitalEncounterSection
Hospital Care Episode Section::HospitalCareEpisodeSection
InjuryEv entSection
+ InjuryEventSection
+ StructuredBodyInjuryEventComponent
+ InjuryEventDetailEntry
PreHospital Encounter Section
+ PreHospitalEncounterSection
+ StructoredBodyPreHospitalEncounterComponent
+ PreHospitalEncounterDetail
Hospital Care Episode Section
+ HospitalCareEpisodeSection
+ StructuredBodyHospitalCareEpisodeComponent
+ HospitalCareEpisodeActivityDetail
Name: TraumaRegistrySubmissionDocumentAuthor: Salimah ShakirVersion: 1.0Created: 2/7/2013 9:30:31 PMUpdated: 6/14/2013 12:01:15 AM
Act
Entity
Role
Participation
ActRelationship
Foriegn Class
Legend
1..11
1..1
1
1..1
1
1..1
1
1..1
1
1..1
1
0..1
1
1..1
1
HEADER
BODY
ENTRIES
© 2014 All Rights ReservedSlide Number: 76
Dict to DAM to CIM to IGNTDB Dictionary Element CDA Template CDA ITEM CDA Clone CDA Attribute CDA CONF
D_01: PATIENT’S HOME ZIP CODE 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_02: PATIENT’S HOME COUNTRY 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_03: PATIENT’S HOME STATE 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_04: PATIENT’S HOME COUNTY 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_05: PATIENT’S HOME CITY 3.1 Trauma Registry Submission Document 8.c.111 patientRole addr 27773D_06: ALTERNATE HOME RESIDENCE 5.3 Patient Demographic Observations Organizer 42.c.iv observation value 30000D_07: DATE OF BIRTH 3.1 Trauma Registry Submission Document 8.c.iv.4 patient birthTime 27776D_08: AGE 5.3 Patient Demographic Observations Organizer 43.c.iv observation value 30008D_09: AGE UNITS 5.3 Patient Demographic Observations Organizer 43.c.iv.1 observation value@unit 30455D_10: RACE 5.3 Patient Demographic Observations Organizer 44.c.iv observation value 30508D_11: ETHNICITY 3.1 Trauma Registry Submission Document 8.c.iv.5 patient ethnicGroupCode 27778D_12: SEX 3.1 Trauma Registry Submission Document 8.c.iv.3 patient administrativeGenderCode 27775DG_01: CO-MORBID CONDITIONS 6.5 Hospital Care Episode Observation Organizer 84.c.iv observation value 30385DG_02: ICD-9 INJURY DIAGNOSES 6.5 Hospital Care Episode Observation Organizer 85.c.iv observation value 30397DG_03: ICD-10 INJURY DIAGNOSES 6.5 Hospital Care Episode Observation Organizer 85.c.iv observation value 30397ED_01: ED/HOSPITAL ARRIVAL DATE 5.1 Hospital Care Episode Encounter 31 encounter effectiveTime 30341ED_02: ED/HOSPITAL ARRIVAL TIME 5.1 Hospital Care Episode Encounter 31 encounter effectiveTime 30341ED_03: INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE 6.1 Circulatory System Observation Entry 63.c.iv observation value 29639ED_043: INITIAL ED/HOSPITAL PULSE RATE 6.1 Circulatory System Observation Entry 62.c.iv observation value 29633ED_05: INITIAL ED/HOSPITAL TEMPERATURE 6.7 Hospital Care Physiological Observation 100.c.iv observation value 30431ED_06: INITIAL ED/HOSPITAL RESPIRATORY RATE 6.16 Respiratory System Observation Entry 145.c.iv observation value 30092ED_07: INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE 6.15 Respiratory System Observation 140.c.iv observation value 30437ED_08: INITIAL ED/HOSPITAL OXYGEN SATURATION 6.16 Respiratory System Observation Entry 144.c.iv observation value 30085ED_09: INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN 6.15 Respiratory System Observation 141.c.iv observation value 30441
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Trauma Registry Data Submission IG
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Front Matter: Introduction and Specification Overview
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Conformance Verbs
• The conformance verb keyword at the start of a constraint ( SHALL , SHOULD , MAY, etc.) indicates usage conformance. – SHALL is an indication that the constraint is to
be enforced without exception; – SHOULD is an indication that the constraint is
optional but highly recommended; and – MAY is an indication that the constraint is
optional and that adherence to the constraint is at the discretion of the document creator.
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Cardinality
• The cardinality indicator (0..1, 0..*, 1..1, 1..*, etc.) specifies the allowable occurrences within an instance.
• Thus, " MAY contain 0..1" and " SHOULD contain 0..1" both allow for a document to omit the particular component, but the latter is a stronger recommendation that the component be included if it is known.
• The following cardinality indicators may be interpreted as follows:– 0..1 as contains zero or one– 1..1 as contains exactly one– 2..2 as contains exactly two– 1..* as contains one or more– 0..* as contains zero or more
• Each constraint is uniquely identified (e.g., "CONF:605") by an identifier placed at or near the end of the constraint.
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Value Set Binding
• Value set bindings adhere to HL7 Vocabulary Working Group best practices, and include both a conformance verb ( SHALL , SHOULD , MAY, etc.) and an indication of DYNAMIC vs. STATIC binding.
• The use of SHALL requires that the component be valued with a member from the cited value set; however, in every case any HL7 "null" value such as other (OTH) or unknown (UNK) may be used.
• STATIC binding means that the allowed values of the value set do not change automatically as new values are added to a value set. That is, the binding is to a single version of a value set.
• DYNAMIC binding means that the intent is to have the allowed values for a coded item automatically change (expand or contract) as the value set is maintained over time.
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Templates
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Document Template
83
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Section Templates
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Entry Templates
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Subentry Templates
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Vocabulary Tables
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Implementation Guide Development
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From Data Dict. to CDA Impl. Guide
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UMTS Project Consolidated Dictionary and
IHE Content Profile Development
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Registry Elements
MedicationAdministration
00307 Medication
MedicationTypeCode
MedicationClassCode
T iming
At Discharge
Pre-Encounter
First 24 Hours
Intra-Encounter
Intra-Procedure
Pre-Procedure
00776 Route
Initial Bolus
Initial Infusion
00238 Frequency
q12hr
q24hr
00423 Status
Administered
Not Administered
Blinded
Contraindicated
00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time
00303 Dose Code
Full Reduced Other
Within 2 weeks
During Follow-up
Semantic Analysis
DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause
00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.
First Medical Contact
00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.
First Medical Contact PreHospital
00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.
First Medical Contact Outside Facility
00112 Cardiac Arrest Indicator Action.9035 Cardiac Arrest H. In-Hospital Clinical Events Indicate if the patient experienced an episode of cardiac arrest in your facility.
In Hospital
00112 Cardiac Arrest Indicator CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure.
within 24 hours of procedure
00112 Cardiac Arrest Indicator ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia.
History and Risk Factors Pre-Hospital
00800 VTach/VFib Arrest Indicator ICD.4090 VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of ventricular tachycardia or ventricular fibrillation.
History and Risk Factors ventricular tachycardia or ventricular fibrillation
00102 Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of bradycardia.
History and Risk Factors bradycardia
00112 Cardiac Arrest Indicator ICD.8005 Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest.
Intra or Post Procedure
00112 Cardiac Arrest Indicator Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Indicate if there was a cardiac arrest event that required CPR.
Intra or Post Procedure
00112 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours D. Pre-Procedure Status Indicate if the patient has had an episode of cardiac arrest within 24 hours of the procedure.
within 24 hours of the procedure
Consolidated Dictionary
0 1 .0 S ubm is s ions ::P a rtic ipa ntIde ntifie r
- i d e n ti f i e rV a l u e :S T
+ i d e n ti f i e rT yp e Co d e :P a rti c i p a n tId e n ti f i e r
0 1 .0 S ubm is s ions ::P a rtic ipa nt
- n a m e :S T
0 1 .0 S ubm is s ions ::S ubm is s ion
- i d e n ti f i e r :S T
+ su b m i ssi o n T i m e P e ri o d :T S .DA T E (IV L )
+ su b m i ssi o n Da te T i m e :T S
0 1 .0 S ubm is s ions ::S ourc e S ys te m P rov ide r
- i d e n ti f i e r :S T {i d }
0 1 .0 S ubm is s ions ::S ourc e S ys te m
- ve rsi o n Id e n ti f i e r :S T
0 1 .0 S ubm is s ions ::Re gis try
- i d e n ti f i e r :S T {i d }
- ve rsi o n Id e n ti f i e r :S T {i d }
0 3 .0 Ca re E pis ode s ::Ca re E pis ode
- a rri va l Da te T i m e :T S
- d i sch a rg e Da te :T S .DA T E
- p a yo rT yp e Co d e :CD [1 ..* ] (S E T )
- a d m i ssi o n S o u rce Co d e :CD
- d i sch a rg e D i sp o si t i o n Co d e :CD
0 2 .0 P a tie nts ::P a tie ntRa c e
- ra ce Co d e :CD
- ra ce De ta i l Co d e :CD [0 ..* ] (S E T )
0 2 .0 P a tie nts ::P a tie nt
- n a m e :E N.P N
- b i rth Da te :T S .DA T E
- se xCo d e :CD
- h i sp a n i c In d i ca to r :B L = No
- e th n i c i tyDe ta i l Co d e :CD [0 ..* ] (S E T )
- p o sta l Zo n e Id e n ti f i e r : I I
+ re si d e n ce Co u n tryCo d e :CD
0 2 .0 P a tie nts ::P a tie ntIde ntifie r
- i d e n ti f i e rV a l u e : I I
+ i d e n ti f i e rT yp e Co d e :P a ti e n tId e n ti f i e r
0 2 .0 P a tie nts ::Re s e a rc hS tudyE nrollm e nt
- e n ro l l e d In d i ca to r :B L = No
0 2 .0 P a tie nts ::C lin ic a lTria l
- tri a l T yp e Co d e :CD
- re se a rch S tu d yNa m e :S T
0 3 .0 Ca re E pis ode s ::E v e ntE pis ode Re la tion
+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e
0 4 .0 O bs e rv a tions ::Inv olv e dAna tom ic S ite
+ i n vo l ve m e n tT yp e Co d e : In vo l ve m e n tT yp e
0 4 .0 O bs e rv a tions ::
O bs e rv a tionE v e nt
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 4 .0 O bs e rv a tions ::O bs e rv a tionRe s ult
- o b se rva ti o n Re su l tT yp e Co d e :CD
- co n d i t i o n O n se tDa te T i m e :T S [0 ..1 ]
- e st i m a te d O n si te Da te In d i ca to r :B L = No
- m i ssi n g O n se tT i m e In d i ca to r :B L = No
- o b se rva ti o n V a l u e :A NY
+ o b se rva ti o n V a l u e Ne g a ti o n In d i ca to r :B L = No
0 5 .0 E v e nts ::E v e nt
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 5 .0 E v e nts ::E v e ntE v e ntRe la tion
+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e
0 5 .0 E v e nts ::E v e ntP e rform e r
- n a m e :E N.P N
- i d e n ti f i e r : I I
- i sCe rt i f i e d In d i ca to r :B L = No
0 5 .0 E v e nts ::In te rv e ntion
- i n d i ca ti o n Co d e :CD [0 ..1 ]
- a b o rte d Re a so n Co d e :CD [0 ..* ]
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 6 .0 Le s ions ::Le s ion
- l e si o n Co u n te r : INT {i d }
0 6 .0 Le s ions ::Le s ionAffe c te dV e s s e lS e gm e nt
- l e si o n L o ca ti o n Co d e :CD
- se g m e n tCo u n te r : INT
0 6 .0 Le s ions ::Le s ionDe s c riptor
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 6 .0 Le s ions ::Le s ionTre a tm e ntDe v ic e
- d e v i ce Co u n te r : INT
0 7 .0 De v ic e s ::De v ic e
- i d e n ti f i e r : I I
- typ e Co d e :CD
- m a n u fa ctu re rNa m e :E N .O N
- d e v i ce Na m e :S T
- u n i ve rsa l De vi ce Id e n ti f i e r : I I [0 ..1 ]
0 7 .0 De v ic e s ::De v ic e De s c riptor
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 8 .0 Ana tom ic S ite s ::Ana tom ic Re gion
- a n o to m i cRe g i o n Co d e :CD
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::Ana tom ic S ite
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rG ra ft
- g ra ftT yp e Co d e :CD
: :Ca rd i o va scu l a rV e sse l
- ca rd i o va scu l a rV e sse l Co d e :CD {i d }
- ve sse l T yp e Co d e :CD
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rV e s s e l
- ca rd i o va scu l a rV e sse l Co d e :CD {i d }
- ve sse l T yp e Co d e :CD
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::V e s s e lS e gm e nt
- ve sse l S e g m e n tCo d e :CD {i d }
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 9 .0 P roc e dure s ::Arte ria lAc c e s s
- si te Co u n te r :INT
- d i re ct i o n a l i tyT yp e Co d e :CD [0 ..1 ]
- ve sse l Co d e :CD
0 9 .0 P roc e dure s ::Arte ria lC los ure
- a rte ri a l C l o su re Co u n te r :INT {i d }
- m e th o d Co d e :CD [0 ..1 ]
- u n d o cu m e n te d In d i ca to r :B L = No
0 9 .0 P roc e dure s ::Arte ria lC los ure De v ic e
- d e v i ce Co u n te r : INT
0 9 .0 P roc e dure s ::P roc e dure
+ p ro ce d u re T yp e Co d e :CD
: : In te rve n ti o n
- i n d i ca ti o n Co d e :CD [0 ..1 ]
- a b o rte d Re a so n Co d e :CD [0 ..* ]
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure De v ic e Us e
- d e v i ce Co u n te r : INT {i d }
- sta tu sCo d e :CD
- a b o rte d Re a so n Co d e :CD [0 ..1 ]
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure De s c riptor
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure Le s ion
- p re v i o u sl yT re a te d In d i ca to r :B L = No
- cu l p ri tL e si o n In d i ca to r :B L = No
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure V a s c ula rAs s e s s m e nt
- ve sse l No tA va i l a b l e In d i ca to r :B L = No
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::
M e dic a tion
+ m e d i ca ti o n Co d e :CD
- n a m e :S T
1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::
M e dic a tionAdm inis tra tionE v e nt
: : In te rve n ti o n
- i n d i ca ti o n Co d e :CD [0 ..1 ]
- a b o rte d Re a so n Co d e :CD [0 ..* ]
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
P ri m a ry C l a ss
De p e n d a n t C l a sse s
V a l u e S e ts
Fo re i g n C l a sse s
Legend
Na m e : NCDR DA M C l a sse s
A u th o r: S a l i m a h S h a ki r
V e rsi o n : 1 .0
Cre a te d : 1 1 /1 2 /2 0 1 2 7 :0 2 :0 0 P M
Up d a te d : 8 /2 6 /2 0 1 3 1 :0 5 :4 4 P M
0 6 .0 Le s ions ::Le s ionTre a tm e ntDe ta il
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
Refers to (1..1)07.0 Devices :: Device
is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice
0 ..*
as
sig
ns
0 . .1
0 ..*
ha
s ta
rge
t
1
0 ..*
is p
art o
f
0 . .*
is u
se
of
1
i s a typ e
o f
i s a typ e
o f
i s a typ e o f
1 ..*
ad
min
iste
rs
1
i s a typ e
o f
is a
typ
e
of
is p
art o
f
i s a typ e
o f
1 ..* {o rd e re d }
i s p a rt o f
0 ..*
i s p a rt o f
0 ..*
inv
olv
ing
1
0 ..*
h a s ta rg e t
1
0 ..*
i n vo l ve d
1
0 ..*
p e rfo rm e d b y
0 ..*
0 ..1
trea
ted
1
0 ..*
i s l o ca te d i n
1
i s a typ e
o f
0 ..*
ha
s s
ub
jec
t
1
0 ..*
ha
s s
ou
rce
1
0 ..*
is p
art o
f
0 . .*
i s p a rt o f
0 ..*
is p
art o
f
+ su b se cti o n
0 ..*i s g ro u p e d b y
0 ..1
0 ..*
a ffe ct i n g
1
0 ..*
i s p a rt o f
0 ..*
i s u se o f
1
0 ..*
i s p a rt o f
0 ..*
is g
rou
pe
d b
y
1 . .*
h a s su b j e ct
1
0 ..1
w i th i n co n te xt o f
1
1 ..*
p ro v i d e d b y
1
1 ..*
su b m i te d to
1
0 ..*
is p
art o
f
1
+ ch i l d
0 ..*
i s g ro u p e d b y
+ p a re n t
0 ..1
0 ..*
h a s so u rce
1
0 ..*
is u
se
d b
y
1
0 ..*
i s tre a tm e n t o f
1
0 ..*
i d e n ti f i e s
1
0 ..*
h a s ta rg e t
10 ..*
ha
s s
ub
jec
t
1
1 ..*
is a
trait o
f
1
0 ..*
i s u se b y
1
is a
typ
e
of
0 . .*
i s tre a te d b y
1
0 ..*
i s p a rt o f
0 ..*
ide
ntifie
s 1
1 ..*
su b m i te d b y
1
1 ..*
orig
ina
tes
from
1
0 ..*
i s p a rt o f
Conceptual Data Model
(CustodianOrganization)Participant
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdentifier.identifierValue) id :II+ (Participant.name) name :EN.ON
(Patient)Patient
- classCode :CS = "PSN"- determinerCode :CS = "INSTANCE"+ (Patient.name) name :EN.PN+ (Patient.sexCode) administrativeGenderCode :CD+ (Patient.birthDate) birthTime :TS.DATE+ (Patient.hispanicIndicator) ethnicGroupCode :CD
(Observation)PatientRaceObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)
(Act)SubmissionAct
- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identifier) id :II+ (Submission.submissionTimePeriod) effectiveTime :TS (IVL)
(PatientRole)PatientRole
- classCode :CS = "PAT"+ (PatientIdentifier.identifierValue) id :II
(ClinicalDocument)CathPCIRegistryDocument
- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveTime :TS
(RecordTarget)RecordTarget
- typeCode :CS = "RCT"- contextControlCode :CS = "OP"
(AssignedCustodian)ParticipantRole
- classCode :CS = "ASSIGNED"
(Custodian)Custodian
- typeCode :CS = "CST"
(StructuredBody)DocumentBody
- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"
(ClinicalDocumentComponent)DocumentComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)SubmissionDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetail"
(StructuredBodyComponent)SubmissionDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)SubmissionActEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(ParticipantRole)SourceSystem
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Author
- typeCode :CS = "AUT"- contextControlCode :CS = "OP"
(Device)DataCollectionSystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdentifier) id :II
(Entity)SourceSystemProvider
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identifier) id :II
(ParticipantRole)TargetRegistry
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Receiver
- typeCode :CS = "RCV"- contextControlCode :CS = "OP"
(Device)RegistrySystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identifier) id.root :II.root+ (RegistryVersionIdentifier) id.extension :II.extension
(Section)PatientDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetail"
(StructuredBodyComponent)PatientDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)PatientRaceObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observation)PatientIdentifierObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdentifier.typeCode) code :CD+ (PatientIdentifier.identifierValue) value :CD
(Entry)PatientIdentifierObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)RegistryParticipantDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...
(StructuredBodyComponent)RegistryParticipantDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observation)ParticipantIdentifierObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdentifier.typeCode) code :CD+ (ParticipantIdentifier.identifierValue) value :CD
(Entry)ParticipantIdentifierObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
Entry Point
1..1
1
1..1
1
1..1 1
1..1
isPlayedBy
1
1..1
1
1..1
isScopedBy
1
1..1
1
1..1
1
1..*1
1..1
isPlayedBy
1
isScopedBy
1..11
1..1
isPlayedBy
1
1..11 0..*1
1..1
1
1..11
Constrained Information Model
Account
name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>
DeviceTask
parameterValue : LIST<ANY>
DiagnosticImage
subjectOrientationCode : CE
Diet
energyQuantity : PQcarbohydrateQuantity : PQ
FinancialContract
paymentTermsCode : CE
FinancialTransaction
amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL
InvoiceElement
modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL
ManagedParticipation
id : SET<II>statusCode : SET<CS>
Observation
value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>
PatientEncounter
preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE
Procedure
methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>
PublicHealthCase
detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE
SubstanceAdministration
routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE
Supply
quantity : PQexpectedUseTime : IVL<TS>
WorkingList
ownershipLevelCode : CE
Container
capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ
Device
manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS
LivingSubject
administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL
ManufacturedMaterial
lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>
Material
formCode : CE
NonPersonLivingSubject
strainText : EDgenderStatusCode : CE
Organization
addr : BAG<AD>standardIndustryClassCode : CE
Person
addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>
Place
mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST
Access
approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ
Employee
jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED
LicensedEntity
recertificationTime : TS
Patient
confidentialityCode : CEveryImportantPersonCode : CE
ActRelationship
typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL
Act
classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE
0..n
1
outboundRelationship
0..n
source1
0..n
1
inboundRelationship
0..n
target
1
LanguageCommunication
languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL
Participation
typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...
0..n
1
0..n
1
Entity
classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE
1
0..n
1
0..n
RoleLink
typeCode : CSeffectiveTime : IVL<TS>
Role
classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>
0..n
1
0..n
10..n0..1
playedRole0..n
player
0..1
0..n0..1
scopedRole
0..n
scoper
0..1
0..n
1
outboundLink 0..n
source1
0..n
1
inboundLink0..n
target1
HL7 Reference Models
HL7 Clinical Document Architecture RMIM UMTS CDA Template Library
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
HL7 & IHE Content Profiles
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
Registry Specific Content Profiles
Standard Clinical Code Systems
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
Registry Specific Business Rules
UMTS Project Activities
1 2
3
45 6
© 2014 All Rights ReservedSlide Number: 92
1. Semantic Analysis
Registry Elements
MedicationAdministration
00307 Medication
MedicationTypeCode
MedicationClassCode
Timing
At Discharge
Pre-Encounter
First 24 Hours
Intra-Encounter
Intra-Procedure
Pre-Procedure
00776 Route
Initial Bolus
Initial Infusion
00238 Frequency
q12hr
q24hr
00423 Status
Administered
Not Administered
Blinded
Contraindicated
00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time
00303 Dose Code
Full Reduced Other
Within 2 weeks
During Follow-up
Topic Area Mind Map
Decompose composite registry elementsInto interrelated atomic concepts
© 2014 All Rights ReservedSlide Number: 93
2. Terminology Definition
MedicationAdministration
00307 Medication
MedicationTypeCode
MedicationClassCode
Timing
At Discharge
Pre-Encounter
First 24 Hours
Intra-Encounter
Intra-Procedure
Pre-Procedure
00776 Route
Initial Bolus
Initial Infusion
00238 Frequency
q12hr
q24hr
00423 Status
Administered
Not Administered
Blinded
Contraindicated
00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time
00303 Dose Code
Full Reduced Other
Within 2 weeks
During Follow-up
Topic Area Mind Map
DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause
00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.
First Medical Contact
00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.
First Medical Contact PreHospital
00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.
First Medical Contact Outside Facility
00112 Cardiac Arrest Indicator Action.9035 Cardiac Arrest H. In-Hospital Clinical Events Indicate if the patient experienced an episode of cardiac arrest in your facility.
In Hospital
00112 Cardiac Arrest Indicator CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure.
within 24 hours of procedure
00112 Cardiac Arrest Indicator ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia.
History and Risk Factors Pre-Hospital
00800 VTach/VFib Arrest Indicator ICD.4090 VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of ventricular tachycardia or ventricular fibrillation.
History and Risk Factors ventricular tachycardia or ventricular fibrillation
00102 Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of bradycardia.
History and Risk Factors bradycardia
00112 Cardiac Arrest Indicator ICD.8005 Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest.
Intra or Post Procedure
00112 Cardiac Arrest Indicator Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Indicate if there was a cardiac arrest event that required CPR.
Intra or Post Procedure
00112 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours D. Pre-Procedure Status Indicate if the patient has had an episode of cardiac arrest within 24 hours of the procedure.
within 24 hours of the procedure
Consolidated Dictionary Standard Clinical Code Systems
Map atomic concepts to controlledclinical terminologies
© 2014 All Rights ReservedSlide Number: 94
3. Conceptual Data Modeling
DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause
00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.
First Medical Contact
00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.
First Medical Contact PreHospital
00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.
First Medical Contact Outside Facility
00112 Cardiac Arrest Indicator Action.9035 Cardiac Arrest H. In-Hospital Clinical Events Indicate if the patient experienced an episode of cardiac arrest in your facility.
In Hospital
00112 Cardiac Arrest Indicator CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure.
within 24 hours of procedure
00112 Cardiac Arrest Indicator ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia.
History and Risk Factors Pre-Hospital
00800 VTach/VFib Arrest Indicator ICD.4090 VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of ventricular tachycardia or ventricular fibrillation.
History and Risk Factors ventricular tachycardia or ventricular fibrillation
00102 Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of bradycardia.
History and Risk Factors bradycardia
00112 Cardiac Arrest Indicator ICD.8005 Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest.
Intra or Post Procedure
00112 Cardiac Arrest Indicator Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Indicate if there was a cardiac arrest event
that required CPR. Intra or Post Procedure
00112 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours D. Pre-Procedure Status Indicate if the patient has had an episode of
cardiac arrest within 24 hours of the procedure.
within 24 hours of the procedure
Consolidated Dictionary
01.0 Submissions::ParticipantIdentifier
- identifierValue :ST+ identifierTypeCode :ParticipantIdentifier
01.0 Submissions::Participant
- name :ST
01.0 Submissions::Submission
- identifier :ST+ submissionTimePeriod :TS.DATE (IVL)+ submissionDateTime :TS
01.0 Submissions::SourceSystemProv ider
- identifier :ST {id}
01.0 Submissions::SourceSystem
- versionIdentifier :ST
01.0 Submissions::Registry
- identifier :ST {id}- versionIdentifier :ST {id}
03.0 CareEpisodes::CareEpisode
- arrivalDateTime :TS- dischargeDate :TS.DATE- payorTypeCode :CD [1..*] (SET)- admissionSourceCode :CD- dischargeDispositionCode :CD
02.0 Patients::PatientRace
- raceCode :CD- raceDetailCode :CD [0..*] (SET)
02.0 Patients::Patient
- name :EN.PN- birthDate :TS.DATE- sexCode :CD- hispanicIndicator :BL = No- ethnicityDetailCode :CD [0..*] (SET)- postalZoneIdentifier :II+ residenceCountryCode :CD
02.0 Patients::PatientIdentifier
- identifierValue :II+ identifierTypeCode :PatientIdentifier
02.0 Patients::ResearchStudyEnrollment
- enrolledIndicator :BL = No
02.0 Patients::ClinicalTrial
- trialTypeCode :CD- researchStudyName :ST
03.0 CareEpisodes::Ev entEpisodeRelation
+ relationshipTypeCode :RelationshipType
04.0 Observ ations::Inv olv edAnatomicSite
+ involvementTypeCode :InvolvementType
04.0 Observ ations::Observ ationEv ent
+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
04.0 Observ ations::Observ ationResult
- observationResultTypeCode :CD- conditionOnsetDateTime :TS [0..1]- estimatedOnsiteDateIndicator :BL = No- missingOnsetTimeIndicator :BL = No- observationValue :ANY+ observationValueNegationIndicator :BL = No
05.0 Ev ents::Ev ent
- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
05.0 Ev ents::Ev entEv entRelation
+ relationshipTypeCode :RelationshipType
05.0 Ev ents::Ev entPerformer
- name :EN.PN- identifier :II- isCertifiedIndicator :BL = No
05.0 Events::Intervention
- indicationCode :CD [0..1]- abortedReasonCode :CD [0..*]
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
06.0 Lesions::Lesion
- lesionCounter :INT {id}
06.0 Lesions::LesionAffectedVesselSegment
- lesionLocationCode :CD- segmentCounter :INT
06.0 Lesions::LesionDescriptor
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
06.0 Lesions::LesionTreatmentDev ice
- deviceCounter :INT
07.0 Dev ices::Dev ice
- identifier :II- typeCode :CD- manufacturerName :EN.ON- deviceName :ST- universalDeviceIdentifier :II [0..1]
07.0 Dev ices::Dev iceDescriptor
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
08.0 AnatomicSites::AnatomicRegion
- anotomicRegionCode :CD
::AnatomicSite- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::AnatomicSite
- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::Cardiov ascularGraft
- graftTypeCode :CD
::CardiovascularVessel- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD
::AnatomicSite- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::Cardiov ascularVessel
- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD
::AnatomicSite- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::VesselSegment
- vesselSegmentCode :CD {id}
::AnatomicSite- typeCode :CD- lateralityCode :CD
09.0 Procedures::ArterialAccess
- siteCounter :INT- directionalityTypeCode :CD [0..1]- vesselCode :CD
09.0 Procedures::ArterialClosure
- arterialClosureCounter :INT {id}- methodCode :CD [0..1]- undocumentedIndicator :BL = No
09.0 Procedures::ArterialClosureDev ice
- deviceCounter :INT
09.0 Procedures::Procedure
+ procedureTypeCode :CD
::Intervention- indicationCode :CD [0..1]- abortedReasonCode :CD [0..*]
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureDev iceUse
- deviceCounter :INT {id}- statusCode :CD- abortedReasonCode :CD [0..1]
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureDescriptor
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureLesion
- previouslyTreatedIndicator :BL = No- culpritLesionIndicator :BL = No
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureVascularAssessment
- vesselNotAvailableIndicator :BL = No
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
10.0 Medication Administration Ev ents::Medication
+ medicationCode :CD- name :ST
10.0 Medication Administration Ev ents::MedicationAdministrationEv ent
::Intervention- indicationCode :CD [0..1]- abortedReasonCode :CD [0..*]
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
Primary Class
Dependant Classes
Value Sets
Foreign Classes
Legend
Name: NCDR DAM ClassesAuthor: Salimah ShakirVersion: 1.0Created: 11/12/2012 7:02:00 PMUpdated: 8/26/2013 1:05:44 PM
06.0 Lesions::LesionTreatmentDetail
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
Refers to (1..1)07.0 Devices :: Device
is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice
0..*
assig
ns
0..1
0..*
ha
s targ
et
1
0..*
is pa
rt of
0..*
is use
of
1
is a typeof
is a typeof
is a type of
1..*
ad
min
isters
1
is a typeof
is a typ
eo
fis p
art o
f
is a typeof
1..* {ordered}
is part of
0..*
is part of
0..*
invo
lving
1
0..*
has target
1
0..*
involved
1
0..*
performed by
0..*
0..1
trea
ted
1
0..*
is located in
1
is a typeof
0..*
ha
s sub
ject
1
0..*
ha
s sou
rce
1
0..*
is pa
rt of
0..*
is part of
0..*
is pa
rt of
+subsection0..*
is grouped by
0..1
0..*
affecting
1
0..*
is part of
0..*
is use of
1
0..*
is part of
0..*
is gro
up
ed
by
1..*
has subject
1
0..1
within context of
1
1..*
provided by
1
1..*
submited to
1
0..*
is pa
rt of
1
+child0..*
is grouped by
+parent0..1
0..*
has source
1
0..*
is use
d b
y
1
0..*
is treatment of
1
0..*
identifies
1
0..*
has target
10..*
ha
s sub
ject
1
1..*
is a tra
it of
1
0..*
is use by
1
is a typ
eo
f
0..*
is treated by
1
0..*
is part of
0..*
ide
ntifie
s 1
1..*
submited by
1
1..*
orig
ina
tes fro
m
1
0..*
is part of
Conceptual Data Model
Account
name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>
DeviceTask
parameterValue : LIST<ANY>
DiagnosticImage
subjectOrientationCode : CE
Diet
energyQuantity : PQcarbohydrateQuantity : PQ
FinancialContract
paymentTermsCode : CE
FinancialTransaction
amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL
InvoiceElement
modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL
ManagedParticipation
id : SET<II>statusCode : SET<CS>
Observation
value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>
PatientEncounter
preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE
Procedure
methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>
PublicHealthCase
detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE
SubstanceAdministration
routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE
Supply
quantity : PQexpectedUseTime : IVL<TS>
WorkingList
ownershipLevelCode : CE
Container
capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ
Device
manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS
LivingSubject
administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL
ManufacturedMaterial
lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>
Material
formCode : CENonPersonLivingSubject
strainText : EDgenderStatusCode : CE
Organization
addr : BAG<AD>standardIndustryClassCode : CE
Person
addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>
Place
mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST
Access
approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ
Employee
jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED
LicensedEntity
recertificationTime : TS
Patient
confidentialityCode : CEveryImportantPersonCode : CE
ActRelationship
typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL
Act
classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE
0..n
1
outboundRelationship
0..n
source1
0..n
1
inboundRelationship
0..n
target
1
LanguageCommunication
languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL
Participation
typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...
0..n
1
0..n
1
Entity
classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE
1
0..n
1
0..n
RoleLink
typeCode : CSeffectiveTime : IVL<TS>
Role
classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>
0..n
1
0..n
10..n0..1
playedRole0..n
player
0..1
0..n0..1
scopedRole
0..n
scoper
0..1
0..n
1
outboundLink 0..n
source1
0..n
1
inboundLink0..n
target1
HL7 Reference Models
Construct a UML model representation ofnormalized terminology concepts
© 2014 All Rights ReservedSlide Number: 95
4. CDA Constraint Modeling01.0 Submissions::ParticipantIdentifier
- identifierValue :ST+ identifierTypeCode :ParticipantIdentifier
01.0 Submissions::Participant
- name :ST
01.0 Submissions::Submission
- identifier :ST+ submissionTimePeriod :TS.DATE (IVL)+ submissionDateTime :TS
01.0 Submissions::SourceSystemProv ider
- identifier :ST {id}
01.0 Submissions::SourceSystem
- versionIdentifier :ST
01.0 Submissions::Registry
- identifier :ST {id}- versionIdentifier :ST {id}
03.0 CareEpisodes::CareEpisode
- arrivalDateTime :TS- dischargeDate :TS.DATE- payorTypeCode :CD [1..*] (SET)- admissionSourceCode :CD- dischargeDispositionCode :CD
02.0 Patients::PatientRace
- raceCode :CD- raceDetailCode :CD [0..*] (SET)
02.0 Patients::Patient
- name :EN.PN- birthDate :TS.DATE- sexCode :CD- hispanicIndicator :BL = No- ethnicityDetailCode :CD [0..*] (SET)- postalZoneIdentifier :II+ residenceCountryCode :CD
02.0 Patients::PatientIdentifier
- identifierValue :II+ identifierTypeCode :PatientIdentifier
02.0 Patients::ResearchStudyEnrollment
- enrolledIndicator :BL = No
02.0 Patients::ClinicalTrial
- trialTypeCode :CD- researchStudyName :ST
03.0 CareEpisodes::Ev entEpisodeRelation
+ relationshipTypeCode :RelationshipType
04.0 Observ ations::Inv olv edAnatomicSite
+ involvementTypeCode :InvolvementType
04.0 Observ ations::Observ ationEv ent
+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
04.0 Observ ations::Observ ationResult
- observationResultTypeCode :CD- conditionOnsetDateTime :TS [0..1]- estimatedOnsiteDateIndicator :BL = No- missingOnsetTimeIndicator :BL = No- observationValue :ANY+ observationValueNegationIndicator :BL = No
05.0 Ev ents::Ev ent
- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
05.0 Ev ents::Ev entEv entRelation
+ relationshipTypeCode :RelationshipType
05.0 Ev ents::Ev entPerformer
- name :EN.PN- identifier :II- isCertifiedIndicator :BL = No
05.0 Events::Intervention
- indicationCode :CD [0..1]- abortedReasonCode :CD [0..*]
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
06.0 Lesions::Lesion
- lesionCounter :INT {id}
06.0 Lesions::LesionAffectedVesselSegment
- lesionLocationCode :CD- segmentCounter :INT
06.0 Lesions::LesionDescriptor
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
06.0 Lesions::LesionTreatmentDev ice
- deviceCounter :INT
07.0 Dev ices::Dev ice
- identifier :II- typeCode :CD- manufacturerName :EN.ON- deviceName :ST- universalDeviceIdentifier :II [0..1]
07.0 Dev ices::Dev iceDescriptor
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
08.0 AnatomicSites::AnatomicRegion
- anotomicRegionCode :CD
::AnatomicSite- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::AnatomicSite
- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::Cardiov ascularGraft
- graftTypeCode :CD
::CardiovascularVessel- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD
::AnatomicSite- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::Cardiov ascularVessel
- cardiovascularVesselCode :CD {id}- vesselTypeCode :CD
::AnatomicSite- typeCode :CD- lateralityCode :CD
08.0 AnatomicSites::VesselSegment
- vesselSegmentCode :CD {id}
::AnatomicSite- typeCode :CD- lateralityCode :CD
09.0 Procedures::ArterialAccess
- siteCounter :INT- directionalityTypeCode :CD [0..1]- vesselCode :CD
09.0 Procedures::ArterialClosure
- arterialClosureCounter :INT {id}- methodCode :CD [0..1]- undocumentedIndicator :BL = No
09.0 Procedures::ArterialClosureDev ice
- deviceCounter :INT
09.0 Procedures::Procedure
+ procedureTypeCode :CD
::Intervention- indicationCode :CD [0..1]- abortedReasonCode :CD [0..*]
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureDev iceUse
- deviceCounter :INT {id}- statusCode :CD- abortedReasonCode :CD [0..1]
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureDescriptor
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureLesion
- previouslyTreatedIndicator :BL = No- culpritLesionIndicator :BL = No
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
09.0 Procedures::ProcedureVascularAssessment
- vesselNotAvailableIndicator :BL = No
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
10.0 Medication Administration Ev ents::Medication
+ medicationCode :CD- name :ST
10.0 Medication Administration Ev ents::MedicationAdministrationEv ent
::Intervention- indicationCode :CD [0..1]- abortedReasonCode :CD [0..*]
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
Primary Class
Dependant Classes
Value Sets
Foreign Classes
Legend
Name: NCDR DAM ClassesAuthor: Salimah ShakirVersion: 1.0Created: 11/12/2012 7:02:00 PMUpdated: 8/26/2013 1:05:44 PM
06.0 Lesions::LesionTreatmentDetail
::ObservationEvent+ observationTypeCode :CD
::Event- methodCode :CD [0..*] (SET)+ classificationCode :Clasification+ contextCode :Context- eventDateTime :TS [0..1] (IVL)- statusCode :CD = Completed- eventDuration :PQ.TIME [0..1]
Refers to (1..1)07.0 Devices :: Device
is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice
0..*
assig
ns
0..1
0..*
ha
s targ
et
1
0..*
is pa
rt of
0..*
is use
of
1
is a typeof
is a typeof
is a type of
1..*
ad
min
isters
1
is a typeof
is a typ
eo
fis p
art o
f
is a typeof
1..* {ordered}
is part of
0..*
is part of
0..*
invo
lving
1
0..*
has target
1
0..*
involved
1
0..*
performed by
0..*
0..1
trea
ted
1
0..*
is located in
1
is a typeof
0..*
ha
s sub
ject
1
0..*
ha
s sou
rce
1
0..*
is pa
rt of
0..*
is part of
0..*
is pa
rt of
+subsection0..*
is grouped by
0..1
0..*
affecting
1
0..*
is part of
0..*
is use of
1
0..*
is part of
0..*
is gro
up
ed
by
1..*
has subject
1
0..1
within context of
1
1..*
provided by
1
1..*
submited to
1
0..*
is pa
rt of
1
+child0..*
is grouped by
+parent0..1
0..*
has source
1
0..*
is use
d b
y
1
0..*
is treatment of
1
0..*
identifies
1
0..*
has target
10..*
ha
s sub
ject
1
1..*
is a tra
it of
1
0..*
is use by
1
is a typ
eo
f
0..*
is treated by
1
0..*
is part of
0..*
ide
ntifie
s 1
1..*
submited by
1
1..*
orig
ina
tes fro
m
1
0..*
is part of
Conceptual Data Model
(CustodianOrganization)Participant
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdentifier.identifierValue) id :II+ (Participant.name) name :EN.ON
(Patient)Patient
- classCode :CS = "PSN"- determinerCode :CS = "INSTANCE"+ (Patient.name) name :EN.PN+ (Patient.sexCode) administrativeGenderCode :CD+ (Patient.birthDate) birthTime :TS.DATE+ (Patient.hispanicIndicator) ethnicGroupCode :CD
(Observation)PatientRaceObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)
(Act)SubmissionAct
- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identifier) id :II+ (Submission.submissionTimePeriod) effectiveTime :TS (IVL)
(PatientRole)PatientRole
- classCode :CS = "PAT"+ (PatientIdentifier.identifierValue) id :II
(ClinicalDocument)CathPCIRegistryDocument
- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveTime :TS
(RecordTarget)RecordTarget
- typeCode :CS = "RCT"- contextControlCode :CS = "OP"
(AssignedCustodian)ParticipantRole
- classCode :CS = "ASSIGNED"
(Custodian)Custodian
- typeCode :CS = "CST"
(StructuredBody)DocumentBody
- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"
(ClinicalDocumentComponent)DocumentComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)SubmissionDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetail"
(StructuredBodyComponent)SubmissionDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)SubmissionActEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(ParticipantRole)SourceSystem
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Author
- typeCode :CS = "AUT"- contextControlCode :CS = "OP"
(Dev ice)DataCollectionSystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdentifier) id :II
(Entity)SourceSystemProv ider
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identifier) id :II
(ParticipantRole)TargetRegistry
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Receiver
- typeCode :CS = "RCV"- contextControlCode :CS = "OP"
(Dev ice)RegistrySystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identifier) id.root :II.root+ (RegistryVersionIdentifier) id.extension :II.extension
(Section)PatientDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetail"
(StructuredBodyComponent)PatientDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)PatientRaceObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observation)PatientIdentifierObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdentifier.typeCode) code :CD+ (PatientIdentifier.identifierValue) value :CD
(Entry)PatientIdentifierObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)RegistryParticipantDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...
(StructuredBodyComponent)RegistryParticipantDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observation)ParticipantIdentifierObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdentifier.typeCode) code :CD+ (ParticipantIdentifier.identifierValue) value :CD
(Entry)ParticipantIdentifierObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
Entry Point
1..1
1
1..1
1
1..1 1
1..1
isPlayedBy
1
1..1
1
1..1
isScopedBy
1
1..1
1
1..1
1
1..*1
1..1
isPlayedBy
1
isScopedBy
1..11
1..1
isPlayedBy
1
1..11 0..*1
1..1
1
1..11
Constrained Information ModelHL7 Clinical Document Architecture RMIM
Map UMTS Conceptual Data Model to theHL7 Clinical Document Architecture
© 2014 All Rights ReservedSlide Number: 96
5. UMTS CDA Template Construction
(CustodianOrganization)Participant
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdenti fier.identi fierValue) id :II+ (Participant.name) name :EN.ON
(Patient)Patient
- classCode :CS = "PSN"- determinerCode :CS = "INSTANCE"+ (Patient.name) name :EN.PN+ (Patient.sexCode) administrativeGenderCode :CD+ (Patient.birthDate) birthT ime :TS.DATE+ (Patient.hispanicIndicator) ethnicGroupCode :CD
(Observ ation)PatientRaceObserv ation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)
(Act)SubmissionAct
- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identi fier) id :II+ (Submission.submissionT imePeriod) effectiveT ime :TS (IVL)
(PatientRole)PatientRole
- classCode :CS = "PAT"+ (PatientIdenti fier.identi fierValue) id :II
(ClinicalDocument)CathPCIRegistryDocument
- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveT ime :TS
(RecordTarget)RecordTarget
- typeCode :CS = "RCT"- contextControlCode :CS = "OP"
(AssignedCustodian)ParticipantRole
- classCode :CS = "ASSIGNED"
(Custodian)Custodian
- typeCode :CS = "CST"
(StructuredBody)DocumentBody
- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"
(ClinicalDocumentComponent)DocumentComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)SubmissionDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetai l"
(StructuredBodyComponent)SubmissionDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)SubmissionActEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(ParticipantRole)SourceSystem
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Author
- typeCode :CS = "AUT"- contextControlCode :CS = "OP"
(Dev ice)DataCollectionSystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdenti fier) id :II
(Entity)SourceSystemProv ider
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identi fier) id :II
(ParticipantRole)TargetRegistry
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Receiv er
- typeCode :CS = "RCV"- contextControlCode :CS = "OP"
(Dev ice)RegistrySystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identi fier) id.root :II.root+ (RegistryVersionIdenti fier) id.extension :II.extension
(Section)PatientDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetai l"
(StructuredBodyComponent)PatientDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)PatientRaceObserv ationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observ ation)PatientIdentifierObserv ation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdenti fier.typeCode) code :CD+ (PatientIdenti fier.identi fierValue) value :CD
(Entry)PatientIdentifierObserv ationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)RegistryParticipantDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...
(StructuredBodyComponent)RegistryParticipantDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observ ation)ParticipantIdentifierObserv ation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdenti fier.typeCode) code :CD+ (ParticipantIdenti fier.identi fierValue) value :CD
(Entry)ParticipantIdentifierObserv ationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
Entry Point
1..1
1
1..1
1
1..1 1
1..1
isPlayedBy
1
1..1
1
1..1
isScopedBy
1
1..1
1
1..1
1
1..*1
1..1
isPlayedBy
1
isScopedBy
1..11
1..1
isPlayedBy
1
1..11 0..*1
1..1
1
1..11
Constrained Information Model UMTS CDA Template Library
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
HL7 & IHE Content Profiles
Specify registry agnostic CDA element usage,cardinality, and value constraints
© 2014 All Rights ReservedSlide Number: 97
6. Registry Content Profile Specification
UMTS CDA Template Library
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
Registry Specific Content Profiles
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
Registry Specific Business Rules
Specify registry specific CDA element usage,cardinality, and value constraints
© 2014 All Rights ReservedSlide Number: 98
Registry Elements
MedicationAdministration
00307 Medication
MedicationTypeCode
MedicationClassCode
T iming
At Discharge
Pre-Encounter
First 24 Hours
Intra-Encounter
Intra-Procedure
Pre-Procedure
00776 Route
Initial Bolus
Initial Infusion
00238 Frequency
q12hr
q24hr
00423 Status
Administered
Not Administered
Blinded
Contraindicated
00069 Dose Amount00147 Duration00070 Start Date Time00306 Stop Date Time
00303 Dose Code
Full Reduced Other
Within 2 weeks
During Follow-up
Semantic Analysis
DEI Dictionary Element REI Registry Element Name RE Section Coding Instructions Context Timing Location Cause
00112 Cardiac Arrest Indicator Action.4135 Cardiac Arrest at First Medical Contact C. Cardiac Status on First Medical Contact Indicate if the patient has had an episode of cardiac arrest.
First Medical Contact
00112 Cardiac Arrest Indicator Action.4140 Cardiac Arrest Pre-Hospital C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest was prior to arrival at the outside facility and/or occurred during transfer from the outside facility to this facility.
First Medical Contact PreHospital
00112 Cardiac Arrest Indicator Action.4145 Cardiac Arrest Outside Facility C. Cardiac Status on First Medical Contact Indicate if the patient’s cardiac arrest occurred at the outside facility.
First Medical Contact Outside Facility
00112 Cardiac Arrest Indicator Action.9035 Cardiac Arrest H. In-Hospital Clinical Events Indicate if the patient experienced an episode of cardiac arrest in your facility.
In Hospital
00112 Cardiac Arrest Indicator CathPCI.5065 Cardiac Arrest w/in 24 Hours D. Cath Lab Visit Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure.
within 24 hours of procedure
00112 Cardiac Arrest Indicator ICD.4080 Cardiac Arrest Pre-Hospital C. History and Risk Factors Indicate if the patient experienced cardiac arrest due to arrhythmia.
History and Risk Factors Pre-Hospital
00800 VTach/VFib Arrest Indicator ICD.4090 VTach/VFib Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of ventricular tachycardia or ventricular fibrillation.
History and Risk Factors ventricular tachycardia or ventricular fibrillation
00102 Bradycardia Arrest Indicator ICD.4095 Bradycardia Arrest C. History and Risk Factors Indicate if the cardiac arrest was a result of bradycardia.
History and Risk Factors bradycardia
00112 Cardiac Arrest Indicator ICD.8005 Cardiac Arrest H. Intra or Post Procedure Events Indicate if the patient experienced cardiac arrest.
Intra or Post Procedure
00112 Cardiac Arrest Indicator Impact.8000 Cardiac Arrest L. Intra and Post-Procedure Events Indicate if there was a cardiac arrest event that required CPR.
Intra or Post Procedure
00112 Cardiac Arrest Indicator TVT.5035 Cardiac Arrest w/in 24 Hours D. Pre-Procedure Status Indicate if the patient has had an episode of cardiac arrest within 24 hours of the procedure.
within 24 hours of the procedure
Consolidated Dictionary
0 1 .0 S ubm is s ions ::P a rtic ipa ntIde ntifie r
- i d e n ti f i e rV a l u e :S T
+ i d e n ti f i e rT yp e Co d e :P a rti c i p a n tId e n ti f i e r
0 1 .0 S ubm is s ions ::P a rtic ipa nt
- n a m e :S T
0 1 .0 S ubm is s ions ::S ubm is s ion
- i d e n ti f i e r :S T
+ su b m i ssi o n T i m e P e ri o d :T S .DA T E (IV L )
+ su b m i ssi o n Da te T i m e :T S
0 1 .0 S ubm is s ions ::S ourc e S ys te m P rov ide r
- i d e n ti f i e r :S T {i d }
0 1 .0 S ubm is s ions ::S ourc e S ys te m
- ve rsi o n Id e n ti f i e r :S T
0 1 .0 S ubm is s ions ::Re gis try
- i d e n ti f i e r :S T {i d }
- ve rsi o n Id e n ti f i e r :S T {i d }
0 3 .0 Ca re E pis ode s ::Ca re E pis ode
- a rri va l Da te T i m e :T S
- d i sch a rg e Da te :T S .DA T E
- p a yo rT yp e Co d e :CD [1 ..* ] (S E T )
- a d m i ssi o n S o u rce Co d e :CD
- d i sch a rg e D i sp o si t i o n Co d e :CD
0 2 .0 P a tie nts ::P a tie ntRa c e
- ra ce Co d e :CD
- ra ce De ta i l Co d e :CD [0 ..* ] (S E T )
0 2 .0 P a tie nts ::P a tie nt
- n a m e :E N.P N
- b i rth Da te :T S .DA T E
- se xCo d e :CD
- h i sp a n i c In d i ca to r :B L = No
- e th n i c i tyDe ta i l Co d e :CD [0 ..* ] (S E T )
- p o sta l Zo n e Id e n ti f i e r : I I
+ re si d e n ce Co u n tryCo d e :CD
0 2 .0 P a tie nts ::P a tie ntIde ntifie r
- i d e n ti f i e rV a l u e : I I
+ i d e n ti f i e rT yp e Co d e :P a ti e n tId e n ti f i e r
0 2 .0 P a tie nts ::Re s e a rc hS tudyE nrollm e nt
- e n ro l l e d In d i ca to r :B L = No
0 2 .0 P a tie nts ::C lin ic a lTria l
- tri a l T yp e Co d e :CD
- re se a rch S tu d yNa m e :S T
0 3 .0 Ca re E pis ode s ::E v e ntE pis ode Re la tion
+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e
0 4 .0 O bs e rv a tions ::Inv olv e dAna tom ic S ite
+ i n vo l ve m e n tT yp e Co d e : In vo l ve m e n tT yp e
0 4 .0 O bs e rv a tions ::
O bs e rv a tionE v e nt
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 4 .0 O bs e rv a tions ::O bs e rv a tionRe s ult
- o b se rva ti o n Re su l tT yp e Co d e :CD
- co n d i t i o n O n se tDa te T i m e :T S [0 ..1 ]
- e st i m a te d O n si te Da te In d i ca to r :B L = No
- m i ssi n g O n se tT i m e In d i ca to r :B L = No
- o b se rva ti o n V a l u e :A NY
+ o b se rva ti o n V a l u e Ne g a ti o n In d i ca to r :B L = No
0 5 .0 E v e nts ::E v e nt
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 5 .0 E v e nts ::E v e ntE v e ntRe la tion
+ re l a t i o n sh i p T yp e Co d e :Re l a t i o n sh i p T yp e
0 5 .0 E v e nts ::E v e ntP e rform e r
- n a m e :E N.P N
- i d e n ti f i e r : I I
- i sCe rt i f i e d In d i ca to r :B L = No
0 5 .0 E v e nts ::In te rv e ntion
- i n d i ca ti o n Co d e :CD [0 ..1 ]
- a b o rte d Re a so n Co d e :CD [0 ..* ]
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 6 .0 Le s ions ::Le s ion
- l e si o n Co u n te r : INT {i d }
0 6 .0 Le s ions ::Le s ionAffe c te dV e s s e lS e gm e nt
- l e si o n L o ca ti o n Co d e :CD
- se g m e n tCo u n te r : INT
0 6 .0 Le s ions ::Le s ionDe s c riptor
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 6 .0 Le s ions ::Le s ionTre a tm e ntDe v ic e
- d e v i ce Co u n te r : INT
0 7 .0 De v ic e s ::De v ic e
- i d e n ti f i e r : I I
- typ e Co d e :CD
- m a n u fa ctu re rNa m e :E N .O N
- d e v i ce Na m e :S T
- u n i ve rsa l De vi ce Id e n ti f i e r : I I [0 ..1 ]
0 7 .0 De v ic e s ::De v ic e De s c riptor
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 8 .0 Ana tom ic S ite s ::Ana tom ic Re gion
- a n o to m i cRe g i o n Co d e :CD
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::Ana tom ic S ite
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rG ra ft
- g ra ftT yp e Co d e :CD
: :Ca rd i o va scu l a rV e sse l
- ca rd i o va scu l a rV e sse l Co d e :CD {i d }
- ve sse l T yp e Co d e :CD
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::Ca rd iov a s c ula rV e s s e l
- ca rd i o va scu l a rV e sse l Co d e :CD {i d }
- ve sse l T yp e Co d e :CD
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 8 .0 Ana tom ic S ite s ::V e s s e lS e gm e nt
- ve sse l S e g m e n tCo d e :CD {i d }
: :A n a to mi cS i te
- typ e Co d e :CD
- l a te ra l i tyCo d e :CD
0 9 .0 P roc e dure s ::Arte ria lAc c e s s
- si te Co u n te r :INT
- d i re ct i o n a l i tyT yp e Co d e :CD [0 ..1 ]
- ve sse l Co d e :CD
0 9 .0 P roc e dure s ::Arte ria lC los ure
- a rte ri a l C l o su re Co u n te r :INT {i d }
- m e th o d Co d e :CD [0 ..1 ]
- u n d o cu m e n te d In d i ca to r :B L = No
0 9 .0 P roc e dure s ::Arte ria lC los ure De v ic e
- d e v i ce Co u n te r : INT
0 9 .0 P roc e dure s ::P roc e dure
+ p ro ce d u re T yp e Co d e :CD
: : In te rve n ti o n
- i n d i ca ti o n Co d e :CD [0 ..1 ]
- a b o rte d Re a so n Co d e :CD [0 ..* ]
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure De v ic e Us e
- d e v i ce Co u n te r : INT {i d }
- sta tu sCo d e :CD
- a b o rte d Re a so n Co d e :CD [0 ..1 ]
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure De s c riptor
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure Le s ion
- p re v i o u sl yT re a te d In d i ca to r :B L = No
- cu l p ri tL e si o n In d i ca to r :B L = No
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
0 9 .0 P roc e dure s ::P roc e dure V a s c ula rAs s e s s m e nt
- ve sse l No tA va i l a b l e In d i ca to r :B L = No
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::
M e dic a tion
+ m e d i ca ti o n Co d e :CD
- n a m e :S T
1 0 .0 M e dic a tion Adm in is tra tion E v e nts ::
M e dic a tionAdm inis tra tionE v e nt
: : In te rve n ti o n
- i n d i ca ti o n Co d e :CD [0 ..1 ]
- a b o rte d Re a so n Co d e :CD [0 ..* ]
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
P ri m a ry C l a ss
De p e n d a n t C l a sse s
V a l u e S e ts
Fo re i g n C l a sse s
Legend
Na m e : NCDR DA M C l a sse s
A u th o r: S a l i m a h S h a ki r
V e rsi o n : 1 .0
Cre a te d : 1 1 /1 2 /2 0 1 2 7 :0 2 :0 0 P M
Up d a te d : 8 /2 6 /2 0 1 3 1 :0 5 :4 4 P M
0 6 .0 Le s ions ::Le s ionTre a tm e ntDe ta il
: :O b se rva ti o n E ve n t
+ o b se rva ti o n T yp e Co d e :CD
: :E ve n t
- m e th o d Co d e :CD [0 ..* ] (S E T )
+ c l a ssi f i ca ti o n Co d e :C l a si f i ca ti o n
+ co n te xtCo d e :Co n te xt
- e ve n tDa te T i m e :T S [0 ..1 ] (IV L )
- sta tu sCo d e :CD = Co m p l e te d
- e ve n tDu ra ti o n :P Q .T IM E [0 ..1 ]
Refers to (1..1)07.0 Devices :: Device
is referred to by (0..*)06.0 Lesions :: LesionTreatmentDevice
0 ..*
as
sig
ns
0 . .1
0 ..*
ha
s ta
rge
t
1
0 ..*
is p
art o
f
0 . .*
is u
se
of
1
i s a typ e
o f
i s a typ e
o f
i s a typ e o f
1 ..*
ad
min
iste
rs
1
i s a typ e
o f
is a
typ
e
of
is p
art o
f
i s a typ e
o f
1 ..* {o rd e re d }
i s p a rt o f
0 ..*
i s p a rt o f
0 ..*
inv
olv
ing
1
0 ..*
h a s ta rg e t
1
0 ..*
i n vo l ve d
1
0 ..*
p e rfo rm e d b y
0 ..*
0 ..1
trea
ted
1
0 ..*
i s l o ca te d i n
1
i s a typ e
o f
0 ..*
ha
s s
ub
jec
t
1
0 ..*
ha
s s
ou
rce
1
0 ..*
is p
art o
f
0 . .*
i s p a rt o f
0 ..*
is p
art o
f
+ su b se cti o n
0 ..*i s g ro u p e d b y
0 ..1
0 ..*
a ffe ct i n g
1
0 ..*
i s p a rt o f
0 ..*
i s u se o f
1
0 ..*
i s p a rt o f
0 ..*
is g
rou
pe
d b
y
1 . .*
h a s su b j e ct
1
0 ..1
w i th i n co n te xt o f
1
1 ..*
p ro v i d e d b y
1
1 ..*
su b m i te d to
1
0 ..*
is p
art o
f
1
+ ch i l d
0 ..*
i s g ro u p e d b y
+ p a re n t
0 ..1
0 ..*
h a s so u rce
1
0 ..*
is u
se
d b
y
1
0 ..*
i s tre a tm e n t o f
1
0 ..*
i d e n ti f i e s
1
0 ..*
h a s ta rg e t
10 ..*
ha
s s
ub
jec
t
1
1 ..*
is a
trait o
f
1
0 ..*
i s u se b y
1
is a
typ
e
of
0 . .*
i s tre a te d b y
1
0 ..*
i s p a rt o f
0 ..*
ide
ntifie
s 1
1 ..*
su b m i te d b y
1
1 ..*
orig
ina
tes
from
1
0 ..*
i s p a rt o f
Conceptual Data Model
(CustodianOrganization)Participant
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (ParticipantIdentifier.identifierValue) id :II+ (Participant.name) name :EN.ON
(Patient)Patient
- classCode :CS = "PSN"- determinerCode :CS = "INSTANCE"+ (Patient.name) name :EN.PN+ (Patient.sexCode) administrativeGenderCode :CD+ (Patient.birthDate) birthTime :TS.DATE+ (Patient.hispanicIndicator) ethnicGroupCode :CD
(Observation)PatientRaceObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# code :CD = "PatientRace"+ (PatientRace.raceCode) value :CD [1..*] (SET)
(Act)SubmissionAct
- classCode :CS = "ACT"- moodCode :CS = "EVN"+ (Submission.identifier) id :II+ (Submission.submissionTimePeriod) effectiveTime :TS (IVL)
(PatientRole)PatientRole
- classCode :CS = "PAT"+ (PatientIdentifier.identifierValue) id :II
(ClinicalDocument)CathPCIRegistryDocument
- classCode :CS = "DOCCLIN"- moodCode :CS = "EVN"+ id :II# code :CE = "CATHPCI"+ effectiveTime :TS
(RecordTarget)RecordTarget
- typeCode :CS = "RCT"- contextControlCode :CS = "OP"
(AssignedCustodian)ParticipantRole
- classCode :CS = "ASSIGNED"
(Custodian)Custodian
- typeCode :CS = "CST"
(StructuredBody)DocumentBody
- classCode :CS = "DOCBODY"- moodCode :CS = "EVN"
(ClinicalDocumentComponent)DocumentComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)SubmissionDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "SubmissionDetail"
(StructuredBodyComponent)SubmissionDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)SubmissionActEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(ParticipantRole)SourceSystem
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Author
- typeCode :CS = "AUT"- contextControlCode :CS = "OP"
(Device)DataCollectionSystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (SourceSystem.versionIdentifier) id :II
(Entity)SourceSystemProvider
- classCode :CS = "ORG"- determinerCode :CS = "INSTANCE"+ (SourceSystemProvider.identifier) id :II
(ParticipantRole)TargetRegistry
- classCode :CS = "MMAT"
(ClinicalStatementParticipant)Receiver
- typeCode :CS = "RCV"- contextControlCode :CS = "OP"
(Device)RegistrySystem
- classCode :CS = "DEV"- determinerCode :CS = "INSTANCE"+ (Registry.identifier) id.root :II.root+ (RegistryVersionIdentifier) id.extension :II.extension
(Section)PatientDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "PatientDetail"
(StructuredBodyComponent)PatientDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Entry)PatientRaceObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observation)PatientIdentifierObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (PatientIdentifier.typeCode) code :CD+ (PatientIdentifier.identifierValue) value :CD
(Entry)PatientIdentifierObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Section)RegistryParticipantDetailSection
- classCode :CS = "DOCSECT"- moodCode :CS = "EVN"# code :CE = "RegistryPartic...
(StructuredBodyComponent)RegistryParticipantDetailComponent
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
(Observation)ParticipantIdentifierObservation
- classCode :CS = "OBS"- moodCode :CS = "EVN"# (ParticipantIdentifier.typeCode) code :CD+ (ParticipantIdentifier.identifierValue) value :CD
(Entry)ParticipantIdentifierObservationEntry
- typeCode :CS = "COMP"- contextConductionIndicator :BL = "true"
Entry Point
1..1
1
1..1
1
1..1 1
1..1
isPlayedBy
1
1..1
1
1..1
isScopedBy
1
1..1
1
1..1
1
1..*1
1..1
isPlayedBy
1
isScopedBy
1..11
1..1
isPlayedBy
1
1..11 0..*1
1..1
1
1..11
Constrained Information Model
Account
name : STbalanceAmt : MOcurrencyCode : CEinterestRateQuantity : RTO<MO,PQ>allowedBalanceQuantity : IVL<MO>
DeviceTask
parameterValue : LIST<ANY>
DiagnosticImage
subjectOrientationCode : CE
Diet
energyQuantity : PQcarbohydrateQuantity : PQ
FinancialContract
paymentTermsCode : CE
FinancialTransaction
amt : MOcreditExchangeRateQuantity : REALdebitExchangeRateQuantity : REAL
InvoiceElement
modifierCode : SET<CE>unitQuantity : RTO<PQ,PQ>unitPriceAmt : RTO<MO,PQ>netAmt : MOfactorNumber : REALpointsNumber : REAL
ManagedParticipation
id : SET<II>statusCode : SET<CS>
Observation
value : ANYinterpretationCode : SET<CE>methodCode : SET<CE>targetSiteCode : SET<CD>
PatientEncounter
preAdmitTestInd : BLadmissionReferralSourceCode : CElengthOfStayQuantity : PQdischargeDispositionCode : CEspecialCourtesiesCode : SET<CE>specialAccommodationCode : SET<CE>acuityLevelCode : CE
Procedure
methodCode : SET<CE>approachSiteCode : SET<CD>targetSiteCode : SET<CD>
PublicHealthCase
detectionMethodCode : CEtransmissionModeCode : CEdiseaseImportedCode : CE
SubstanceAdministration
routeCode : CEapproachSiteCode : SET<CD>doseQuantity : IVL<PQ>rateQuantity : IVL<PQ>doseCheckQuantity : SET<RTO>maxDoseQuantity : SET<RTO>substitutionCode : CE
Supply
quantity : PQexpectedUseTime : IVL<TS>
WorkingList
ownershipLevelCode : CE
Container
capacityQuantity : PQheightQuantity : PQdiameterQuantity : PQcapTypeCode : CEseparatorTypeCode : CEbarrierDeltaQuantity : PQbottomDeltaQuantity : PQ
Device
manufacturerModelName : SCsoftwareName : SClocalRemoteControlStateCode : CE...alertLevelCode : CElastCalibrationTime : TS
LivingSubject
administrativeGenderCode : CEbirthTime : TSdeceasedInd : BLdeceasedTime : TSmultipleBirthInd : BLmultipleBirthOrderNumber : INTorganDonorInd : BL
ManufacturedMaterial
lotNumberText : STexpirationTime : IVL<TS>stabilityTime : IVL<TS>
Material
formCode : CE
NonPersonLivingSubject
strainText : EDgenderStatusCode : CE
Organization
addr : BAG<AD>standardIndustryClassCode : CE
Person
addr : BAG<AD>maritalStatusCode : CEeducationLevelCode : CEraceCode : SET<CE>disabilityCode : SET<CE>livingArrangementCode : CEreligiousAffiliationCode : CEethnicGroupCode : SET<CE>
Place
mobileInd : BLaddr : ADdirectionsText : EDpositionText : EDgpsText : ST
Access
approachSiteCode : CDtargetSiteCode : CDgaugeQuantity : PQ
Employee
jobCode : CEjobTitleName : SCjobClassCode : CEsalaryTypeCode : CEsalaryQuantity : MOhazardExposureText : EDprotectiveEquipmentText : ED
LicensedEntity
recertificationTime : TS
Patient
confidentialityCode : CEveryImportantPersonCode : CE
ActRelationship
typeCode : CSinversionInd : BLcontextControlCode : CScontextConductionInd : BLsequenceNumber : INTpriorityNumber : INTpauseQuantity : PQcheckpointCode : CSsplitCode : CSjoinCode : CSnegationInd : BLconjunctionCode : CSlocalVariableName : STseperatableInd : BL
Act
classCode : CSmoodCode : CSid : SET<II>code : CDnegationInd : BLderivationExpr : STtext : EDstatusCode : SET<CS>effectiveTime : GTSactivityTime : GTSavailabilityTime : TSpriorityCode : SET<CE>confidentialityCode : SET<CE>repeatNumber : IVL<INT>interruptibleInd : BLlevelCode : CEindependentInd : BLuncertaintyCode : CEreasonCode : SET<CE>languageCode : CE
0..n
1
outboundRelationship
0..n
source1
0..n
1
inboundRelationship
0..n
target
1
LanguageCommunication
languageCode : CEmodeCode : CEproficiencyLevelCode : CEpreferenceInd : BL
Participation
typeCode : CSfunctionCode : CDcontextControlCode : CSsequenceNumber : INTnegationInd : BLnoteText : EDtime : IVL<TS>modeCode : CEawarenessCode : CEsignatureCode : CEsignatureText : EDperformInd : BLsubstitutionConditionCode : CE...
0..n
1
0..n
1
Entity
classCode : CSdeterminerCode : CSid : SET<II>code : CEquantity : SET<PQ>name : BAG<EN>desc : EDstatusCode : SET<CS>existenceTime : IVL<TS>telecom : BAG<TEL>riskCode : CEhandlingCode : CE
1
0..n
1
0..n
RoleLink
typeCode : CSeffectiveTime : IVL<TS>
Role
classCode : CSid : SET<II>code : CEnegationInd : BLaddr : BAG<AD>telecom : BAG<TEL>statusCode : SET<CS>effectiveTime : IVL<TS>certificateText : EDquantity : RTOpositionNumber : LIST<INT>
0..n
1
0..n
10..n0..1
playedRole0..n
player
0..1
0..n0..1
scopedRole
0..n
scoper
0..1
0..n
1
outboundLink 0..n
source1
0..n
1
inboundLink0..n
target1
HL7 Reference Models
HL7 Clinical Document Architecture RMIM UMTS CDA Template Library
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
HL7 & IHE Content Profiles
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
Registry Specific Content Profiles
Standard Clinical Code Systems
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
1 SUBENTRY
1.1 ClincalEventObservationSubEntry [observation: templateId 2.16.840.1.113883.3.2898.10.9999 (closed)]
Table 1: ClincalEventObservationSubEntry Contexts
Contained By: Contains:
This template is used to collect clinical event observations made within the scope of the encounter. Observations may be modified by observational semantic qualifiers.
1. SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31958).
2. SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31959).
3. MAY contain zero or one [0..1] @negationInd (CONF:31960).
4. SHALL contain exactly one [1..1] templateId="2.16.840.1.113883.3.2898.10.9999" (CONF:31961).
5. SHALL contain exactly one [1..1] code (CONF:31962).
6. SHALL contain zero or one [0..1] effectiveTime (CONF:31963).
7. SHALL contain exactly one [1..1] value (CONF:31964).
8. MAY contain zero or more [0..*] entryRelationship (CONF:31965).
a. The entryRelationship, if present, SHALL contain exactly one [1..1] @typeCode="OPTN" (CONF:31966).
b. The entryRelationship, if present, SHALL contain exactly one [1..1] @contextConductionInd="true" (CONF:31967).
c. The entryRelationship, if present, SHALL contain exactly one [1..1] observation (CONF:31968).
i. This observation SHALL contain exactly one [1..1] @classCode="OBS" (CONF:31969).
ii. This observation SHALL contain exactly one [1..1] @moodCode="EVN" (CONF:31970).
iii. This observation SHALL contain exactly one [1..1] code (CONF:31971).
iv. This observation SHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:31972).
Registry Specific Business Rules
UMTS Project Activities
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© 2014 All Rights ReservedSlide Number: 99
Questions
© 2014 All Rights ReservedSlide Number: 100
Thank You
AbdulMalik ShakirPresident and Chief Informatics Scientist
Hi3 Solutions | your healthcare standards conformance partner3500 West Olive Ave, Suite # 300, Burbank, CA 91505.
Direct: +1 626 644 4491 | Toll Free: +1 800 918 6520
www.hi3solutions.com | [email protected]