S&I Framework B Data Elements (Harm. Team) October 6, 2011

Admitting and Discharging Diagnoses Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority CodeLOINC Code B Diagnosis Name Type of medical condition the requires monitoring, diagnostic, therapeutic or educational action. B Patient Conditions Summary on patient admitted condition B Problem Observation A problem is a clinical statement that a clinician has noted. In health care it is a condition that requires monitoring or diagnostic, therapeutic, or educational action. It also refers to any unmet or partially met basic human need. A Problem Observation is, where the type of problem needs to be identified or the condition tracked. A Problem Observation can be a valid "standalone" template instance in cases where a simple problem observation is to be sent. B

Equipment Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority CodeEquipment code set B Date Acquired B Date Disposed B IDB Quantity B NameType of Equipment B OwnerResponsible Party B Status B

Invasive and Non-Invasive Procedures Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Act Represents all other types of procedures dressing changeB Act/codeType of instruction “patient instruction" or in the case of an immunization: code=" " B Instructions Narrative Clincians entry of specific medical guidance Follow discharge instructions, as in patient history report B Observation act Procedures that result in new information about a patient but do not cause physical alteration EEGB Observation Entry Time of entry B Observation Status B Observation Performer Name of clinician conducting observation B Procedures act Procedures the alter that physical condition of a patient SplenectomyB Procedure Location Address of clinical setting where procedure was conducted B Represented Organization Name of Organization where procedure was performed B Service Delivery Location Address of clinical setting where procedure was conducted B

Medical History Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority CodeCorresponding code set B Past Medical History Narrative of Patient’s past medical history even if the observations are not relevant to the current procedure at hand Patient has had recent issue with acne that does not seem to be related to any particular cause. Previous concerns of oral cancer was actually irritated gums as a result of mild food allergy. Patient had recent weight gain due to sedentary lifestyle and new job. B

Medication History Name of Data ElementDefinition of Data Element ISO/HL7 Datatype Examples and Guidance Data Element Priority Approach Site code dynamic B Current Active Medications List of current active medications for patient B Drug Vehicle The vehicle for administering a medication. (e.g. saline, dextrose)B Medication History List Entire medication history for patient B Medication Activity Reflections of what a clinician intends a patient to take or medications currently used by patients B Medication Activity StartStart time of current medication B Medication Activity StatusINT or ENV Medication Route code dynamic B Repeat Number a.In "INT" (intent) mood, the repeat number defines the number of allowed administrations. b.In "EVN" (event) mood, the repeat number is the number of occurrences. a.(INT) For example, a repeat number of "3" means that the substance can be administered up to 3 times. a.(EVN) For example, a repeatNumber of "3" in a substance administration event means that the current administration is the 3rd in a series B

Medication History (contd.) Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Quantity If the consumable code is a precoordinated unit dose (e.g. "metoprolol 25mg tablet") then Quantity is a unitless number that indicates the number of products given per administration (e.g. "2", meaning 2 x "metoprolol 25mg tablet"). Not pre-coordinated consumable: If the consumable code is not pre-coordinated (e.g. is simply "metoprolol"), then Quantity must represent a physical quantity e.g. "25" and "mg", specifying the amount of product given per administration. B IndicationRationale for an activity For example, the indication for a prescription of a painkiller might be a headache that is documented in the Problems Section. B Indication Code B Medication Supply Order Date B

Medication History (contd. 2) Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Medication Supply Order Repeat Number of allowed refills B Medication InformationGeneric product name B Medication Information code B Medication Manufacturer Medication Manufacturing Company B Medication Dispenser Address Address of Dispensing organization B Medication Dispenser Assigned Name Doctor who prescribed the medication B Medication Dispenser Name of represented organization B Patient Instructions Patient instructions for a medication activity or fill instructions B Precondition for Substance Administration Name Criterion for administration that can be used to record that the medication is to be administered only when the associated criteria are met WheezingB

Patient Instructions Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Code Defines the type of instruction e.g. code=" " represents immunization B Narrative Provides explanation on patient instructions e.g. “Follow discharge instructions as noted in clinical report” B

Pending Tests and Procedure Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Assigned Entity Clinician responsible for conducting procedures B Context Description of image- guided intervention or imaging service e.g. “Magnetic resonance angiography, lower abdomen; with contrast material” B Effective Time Date and time of scheduled test/procedure B Status B

Physical Exam Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Code B General Status Narrative of patient state findings upon examination e.g. “Alert and in good spirits, no acute distress.” OR could include sections as follows: “Mental Status”, “Psychiatric Findings”, “Chest, Physical Findings” B

Review of Systems Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority CodeRelevant Codeset B Review of Systems Relevant symptoms and functions as systematically gathered by the patient e.g. “Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.” B

Results Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Result ID B Result Date B Result Type B Result Status B Result Interpretation B Result Value B Result Reference Range B

Vital Signs Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Author Clinician conducting the vital signs B Code B Effective Time Clinically effective time of the measurement, which is most likely when the measurement was performed B Observation Narrative around the clinical observation B Observation Code B Result Type Type of Vital Sign administered B Result ValueList of Vital Sign Results B