code: ACCTRECEIVABLE

display: account receivable

definition: An account for collecting charges, reversals, adjustments and payments, including deductibles, copayments, coinsurance (financial transactions) credited or debited to the account receivable account for a patient's encounter.


code: DOSECOND

display: dosage-condition alert

definition: Description:Proposed dosage is inappropriate due to patient's medical condition.

resourceType: Concept


display: ActCoverageLimitCode

definition: Criteria that are applicable to the authorized coverage.


display: Assessed Patient

definition: Assessed patient, therapy is appropriate


code: DNAINT

display: Drug Non-Allergy Intolerance

definition: Hypersensitivity to an agent caused by a mechanism other than an immunologic response to an initial exposure

hierarchy: _ObservationType OINT DINT


code: TRAVINT

display: Common Travel Interaction

definition: Description: An interaction where the exposure participants traveled together in/on the same vehicle/trip (e.g. concurrent co-passengers).


code: ACMEN

display: mental health access

definition: Description:Provide consent to collect, use, disclose, or access mental health information for a patient.


display: School Interaction

definition: Description: Exposure participants' interaction occurred in an academic setting (e.g., participants are fellow students, or student and teacher).


code: DACT

display: drug action detected issue

definition: Description:Proposed therapy may be contraindicated or ineffective based on an existing or recent drug therapy.


code: CWMA

display: certified wound management care

definition: Description:Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.


code: GOVEMP

display: government employee health program

definition:
Definition: A set of codes used to indicate a government program that is an organized structure for administering and funding coverage of a benefit package for covered parties meeting eligibility criteria, typically related to employment, health and financial status. Government programs are established or permitted by legislation with provisions for ongoing government oversight.  Regulation mandates the structure of the program, the manner in which it is funded and administered, covered benefits, provider types, eligibility criteria and financial participation. A government agency is charged with implementing the program in accordance to the regulation

                           Example: Federal employee health benefit program in the U.S.


code: FRAUD

display: potential fraud

definition: Description:The request is suspected to have a fraudulent basis.


code: VLI

display: low valin, leucin, isoleucin

definition: Diet with low content of the amino-acids valin, leucin, and isoleucin, for "maple syrup disease."


code: SECINTPRVABOBS

definition:
Type of security metadata observation made about the integrity provenance of an IT resource (data, information object, service, or system capability), which indicates the entity that made assertions about the resource.  The asserting entity may not be the original informant about the resource.

                           Examples: Types of security integrity provenance asserted by observation metadata, which may value the observation, including:

                           assertions about an IT resource by a patient
                           assertions about an IT resource by a clinician
                           assertions about an IT resource by a device

hierarchy: SECOBS SECINTOBS SECINTPRVOBS


code: PERIOD

display: period

definition: Transaction counts and value totals for the date range specified.


definition: Observation types for specifying criteria used to assert that a subject is included in a particular population.

display: PopulationInclusionObservationType


code: NOCONSENT

display: no consent

definition:
No notification or opportunity is provided for a grantor to assent or dissent to a grantee's terms of agreement.

                           Comment: A "No Consent" policy scheme provides no opportunity for accommodation of an individual's preferences, and may not comply with Fair Information Practice Principles [FIPP] by enabling the data subject to object, access collected information, correct errors, or have accounting of disclosures.

                           Usage Note: The grantee's terms of agreement, may be available to the grantor by reviewing the grantee's privacy policies, but there is no notice by which a grantor is apprised of the policy directly or able to acknowledge.

                           Examples:

                           Healthcare: Without notification or an opportunity to assent or dissent, a patient's health information is automatically included in and available (often according to certain rules) through a health information exchange.  Note that this differs from implied consent, where the patient is assumed to have consented.
                           Without notification or an opportunity to assent or dissent, a patient's health information is collected, accessed, used, or disclosed for research, public health, security, fraud prevention, court order, or law enforcement.
                           Non-healthcare: Without notification or an opportunity to assent or dissent, a consumer's healthcare or non-healthcare internet searches are aggregated for secondary uses such as behavioral tracking and profiling.
                           Without notification or an opportunity to assent or dissent, a consumer's location and activities in a shopping mall are tracked by RFID tags on purchased items.


code: PALL

display: Palliative

definition: Provision of care for patients who are living or dying from an advanced illness.


definition: Set of codes indicating the type of insurance policy or other source of funds to cover healthcare costs.

display: ActInsurancePolicyCode


code: GRANTORCHOICE

display: grantor choice

definition:
A grantor's terms of agreement to which a grantee may assent or dissent, and which may include an opportunity for a grantee to request restrictions or extensions.

                           Comment: A grantor typically is able to stipulate preferred terms of agreement when the grantor has control over the topic of the agreement, which a grantee must accept in full or may be offered an opportunity to extend or restrict certain terms.

                           Usage Note: If the grantor's term of agreement must be accepted in full, then this is considered "basic consent".  If a grantee is offered an opportunity to extend or restrict certain terms, then the agreement is considered "granular consent".

                           Examples:

                           Healthcare: A PHR account holder [grantor] may require any PHR user [grantee]  to accept the terms of agreement in full, or may permit a PHR user to extend or restrict terms selected by the account holder or requested by the PHR user.
                           Non-healthcare: The owner of a resource server [grantor] may require any authorization server [grantee] to meet authorization requirements stipulated in the grantor's terms of agreement.


definition:
Types of sensitivity policies that apply to Roles.

                           Usage Notes: RoleSensitivity codes are used to bind information to a Role.confidentialityCode per organizational policy.  Role.confidentialityCode is defined in the RIM as "an indication of the appropriate disclosure of information about this Role with respect to the playing Entity."

display: RoleInformationSensitivityPolicy


code: CPLYOPP

display: comply with organizational privacy policy

definition: Custodian security system must retrieve, evaluate, and comply with applicable organizational privacy policies associated with the target information.


definition:
Types of sensitivity policies that may apply to a sensitive attribute on an Entity.

                           Usage Note: EntitySensitivity codes are used to convey a policy that is applicable to sensitive information conveyed by an entity attribute.  May be used to bind a Role.confidentialityCode associated with an Entity per organizational policy.  Role.confidentialityCode is defined in the RIM as "an indication of the appropriate disclosure of information about this Role with respect to the playing Entity."

display: EntityInformationSensitivityPolicy


code: CRIT

display: criticality

definition: A clinical judgment as to the worst case result of a future exposure (including substance administration). When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.


code: NETAMT

display: Net Amount

definition: Maximum net amount that will be covered for the product or service specified.


code: CANCAPT

display: cancelled appointment

definition: A charge to compensate the provider when a patient cancels an appointment with insufficient time for the provider to make another appointment with another patient.


code: NOMOU

display: no disclosure without MOU

definition: Prohibition on disclosure without an interagency service agreement or memorandum of understanding (MOU).


code: NOORGPOL

display: no disclosure without organizational authorization

definition: Prohibition on disclosure without organizational authorization.


display: Vacation Supply

definition: Supply date is due to patient vacation


display: Duplicate key identifier

definition: The ID of the patient, order, etc., already exists. Used in response to addition transactions (Admit, New Order, etc.).


code: MISSMAND

display: mandatory element missing

definition: Description:The specified element is mandatory and was not included in the instance.


code: NON

display: Non-Payment Data

definition: Non-Payment Data.


code: HOSPPTNT

display: Hospital Patient Interaction

definition: Description: Exposure participants' interaction occurred when both were patients being treated in the same (acute) health care delivery facility.


code: PSYCH

display: Psychiatric

definition: Provision of treatment of psychiatric disorder relating to mental illness.


code: NODSCLCD

display: no disclosure without consent directive

definition: Prohibition on disclosure without organizational approved patient restriction.


code: LABOE

display: laboratory test order entry task

definition: A clinician creates a request for a laboratory test to be done for a given patient.


code: RMGTCOMPT

display: records management compartment

definition: A security category label field value, which indicates that access and use of an IT resource is restricted to members of records management department or workflow.


code: STD

display: sexually transmitted disease information sensitivity

definition:
Policy for handling sexually transmitted disease information, which will be afforded heightened confidentiality.
 Information handling protocols based on organizational policies related to sexually transmitted disease information that is deemed sensitive.

                           Usage Note: If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


code: W

display: Ward

definition: Accommodations in which there are 3 or more beds.


definition: An identifying data string for A substance used as a medication or in the preparation of medication.

display: ActInvoiceDetailDrugProductCode


display: ActSpecimenTreatmentCode

definition: Set of codes related to specimen treatments


code: LACT

display: Lactation Alert

definition: Proposed therapy may be inappropriate or contraindicated when breast-feeding


code: ADRFSPELAT

display: adjud. refused same-period electronic amount

definition: Identifies the total net amount of all  Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted electronically.


code: HHOBS

display: household situation observation

definition: Indicates that the observation is of a person’s living situation in a household including the household composition and circumstances.


code: SUPPRESSED

display: record suppressed

definition: Description: One or more records in the query response have been suppressed due to consent or privacy restrictions.


code: FIBRIN

display: Fibrin

definition: The Fibrin Index of the specimen. In the case of only differentiating between Absent and Present, recommend using 0 and 1


code: PDNFPPELAT

display: paid nullified prior-period electronic amount

definition: Identifies the total net amount of all  Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted electronically.


display: Provided Patient Education

definition: Provided education or training to the patient on appropriate therapy use


code: LTRMCARE

display: Long Term Care Facility Interaction

definition: Description: Exposure participants' interaction occurred in the course of one or both participants being resident at a long term care facility (second participant may be a visitor, worker, resident or a physical place or object within the facility).


code: DUPTHPY

display: Duplicate Therapy Alert

definition: The proposed therapy appears to duplicate an existing therapy


code: COL

display: collision coverage policy

definition: Definition: An automobile insurance policy under which the insurance company will cover the cost of damages to an automobile owned by the named insured that are caused by accident or intentionally by another party.


code: CHRO

display: certified high risk obstetrics care

definition: Description:Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.


code: HIPAAPsyNotes

display: HIPAA psychotherapy notes

definition:
The U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR Part 164 Section 164.508) requires authorization for certain uses and disclosure of psychotherapy notes.

                           Definition: Authorization that must be obtained for disclosure of psychotherapy notes.

                           Usage Note: May be associated with an Act or a Role to indicate the legal provision to which the assignment of an Act.confidentialityCode or Role.confidentialityCode complies.


code: ANNMED

display: medication note

definition: Description:A note that is specific to a patient's medications, either historical, current or planned.


code: CVSC

display: certified vascular surgery care

definition: Description:Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.


definition:
A code that is used to indicate the type of case safety report received from sender. The current code example reference is from the International Conference on Harmonisation (ICH) Expert Workgroup guideline on Clinical Safety Data Management: Data Elements for Transmission of Individual Case Safety Reports. The unknown/unavailable option allows the transmission of information from a secondary sender where the initial sender did not specify the type of report.

                        Example concepts include: Spontaneous, Report from study, Other.

display: Individual Case Safety Report Type


code: PAYEE

display: payee

definition: Transaction counts and value totals by each instance of an invoice payee.


code: MODEL

display: model

definition: Description: Digital Model Attachment


code: SECINTPRVRBOBS

definition:
Type of security metadata observation made about the integrity provenance of an IT resource (data, information object, service, or system capability), which indicates the entity that reported the existence of the resource.  The reporting entity may not be the original author of the resource.

                           Examples: Types of security integrity provenance reported by observation metadata, which may value the observation, include:

                           reports about an IT resource by a patient
                           reports about an IT resource by a clinician
                           reports about an IT resource by a device


code: GFTH

display: good faith indicator

definition: The medical service was provided to a patient in good faith that they had medical coverage, although no evidence of coverage was available before service was rendered.


code: AMBT

display: ambulance transport

definition: ambulance transport


code: BLDTRNS

display: blood borne transmission

definition: Communication of an agent to a living subject through direct contact with blood or blood products whether the contact with blood is part of  a therapeutic procedure or not.


code: COMC

display: certified occupational medicine care


code: SS

display: short stay

definition: An encounter where the patient is admitted to a health care facility for a predetermined length of time, usually less than 24 hours.


code: NOLIST

display: no unlisted entity disclosure

definition: Prohibition on disclosure except to entities on specific access list.


code: AUDTR

display: audit trail

definition: Custodian system must monitor and maintain retrievable log for each user and operation on information.


code: PROBLISTREV

display: problem list review task

definition: A person reviews a list of problems of a given patient.


code: MISSAPT

display: missed appointment

definition: A charge to compensate the provider when a patient does not show for an appointment.


code: MSRPOPLEX

display: measure population exclusions

definition: Criteria for specifying subjects who should be removed from the eMeasure's Initial Population and Measure Population. Measure Population Exclusions are used in Continuous Variable measures to help narrow the Measure Population before determining the value(s) of the continuous variable(s).


code: EMER

display: emergency

definition: A patient encounter that takes place at a dedicated healthcare service delivery location where the patient receives immediate evaluation and treatment, provided until the patient can be discharged or responsibility for the patient's care is transferred elsewhere (for example, the patient could be admitted as an inpatient or transferred to another facility.)


code: LTC

display: long term care policy

definition:
Definition: An insurance policy that covers benefits for long-term care services people need when they no longer can care for themselves. This may be due to an accident, disability, prolonged illness or the simple process of aging. Long-term care services assist with activities of daily living including:

                              Help at home with day-to-day activities, such as cooking, cleaning, bathing and dressing

                              Care in the community, such as in an adult day care facility

                              Supervised care provided in an assisted living facility

                              Skilled care provided in a nursing home


code: ARCAT

display: adverse drug reaction category

definition: Description: All information pertaining to a patient's adverse drug reactions.


code: MENTPOL

display: mental health policy

definition: Definition: A health insurance policy that covers benefits for mental health services and prescriptions.


code: LIFE

display: life insurance policy

definition:
Definition: A policy under which the insurer agrees to pay a sum of money upon the occurrence of the covered partys death. In return, the policyholder agrees to pay a stipulated amount called a premium at regular intervals.  Life insurance indemnifies the beneficiary for the loss of the insurable interest that a beneficiary has in the life of a covered party.  For persons related by blood, a substantial interest established through love and affection, and for all other persons, a lawful and substantial economic interest in having the life of the insured continue. An insurable interest is required when purchasing life insurance on another person. Specific exclusions are often written into the contract to limit the liability of the insurer; for example claims resulting from suicide or relating to war, riot and civil commotion.

                           Discussion:A life insurance policy may be used by the covered party as a source of health care coverage in the case of  a viatical settlement, which is the sale of a life insurance policy by the policy owner, before the policy matures. Such a sale, at a price discounted from the face amount of the policy but usually in excess of the premiums paid or current cash surrender value, provides the seller an immediate cash settlement. Generally, viatical settlements involve insured individuals with a life expectancy of less than two years. In countries without state-subsidized healthcare and high healthcare costs (e.g. United States), this is a practical way to pay extremely high health insurance premiums that severely ill people face. Some people are also familiar with life settlements, which are similar transactions but involve insureds with longer life expectancies (two to fifteen years).


code: TRSTMEC

display: trust mechanism

definition: Type of security metadata about a security architecture system component that supports enforcement of security policies.


definition: Types of observations that can be made about Preferences.


code: PATDOC

display: patient documentation task

definition: A person enters documentation about a given patient.


code: ACPOLPRG

display: policy or program information access

definition: Description: Provide consent to collect, use, disclose, or access coverage policy or program for a patient.


display: colonoscopy prep

definition: Description:Provision of prescription or direction to consume a product for purposes of bowel clearance in preparation for a colonoscopy.


code: RXCINV

display: Rx compound invoice

definition: Pharmacy dispense invoice for a compound.


code: SP

display: Semi-private

definition: Accommodations in which there are 2 beds.


code: CNMC

display: certified nuclear medicine care

definition: Description:Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.


code: OBSANTV

display: antigen validity

definition: Description: Indicates whether an antigen is valid or invalid.


definition:
Definition: Characterizes how a patient was or will be transported to the site of a patient encounter.

                           Examples: Via ambulance, via public transit, on foot.

display: ActPatientTransportationModeCode


code: NOCOLLECT

display: no collection

definition: Prohibition on collection or storage of the information.


code: PATEDUE

display: patient education entry

definition: A person provides a patient-specific education handout to a patient.

hierarchy: _ActTaskCode PATDOC CLINNOTEE


code: INMATE

display: Inmate Interaction

definition: Description: Exposure participants' interaction occurred in the course of one or both participants being incarcerated at a correctional facility


code: PAF

display: phenylalanine free

definition: Phenylketonuria diet.


code: ENDC

display: endogenous content

definition: A baseline value for the measured test that is inherently contained in the diluent.  In the calculation of the actual result for the measured test, this baseline value is normally considered.


code: CMPMSRSCRWGHT

display: component measure scoring weight

definition: An attribute of a quality measure describing the weight this component measure score is to carry in determining the overall composite measure final score. The value is real value greater than 0 and less than 1.0. Each component measure score will be multiplied by its CMPMSRSCRWGHT and then summed with the other component measures to determine the final overall composite measure score. The sum across all CMPMSRSCRWGHT values within a single composite measure SHALL be 1.0. The value assigned is scoped to the composite measure referencing this component measure only.


code: ENVTRNS

display: environmental exposure transmission

definition: Communication of an agent from an environmental surface or source to a living subject by direct contact.


code: COMPT

display: compartment

definition:
This is the healthcare analog to the US Intelligence Community's concept of a Special Access Program.  Compartment codes may be used in as a field value in an initiator's clearance to indicate permission to access and use an IT Resource with a security label having the same compartment value in security category label field.

                        Map: Aligns with ISO 2382-8 definition of Compartment - "A division of data into isolated blocks with separate security controls for the purpose of reducing risk."


code: CAST

display: certified asthma care

definition: Description:Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.


code: SPLIMAGE

display: image

definition: Description: A characteristic representing a single file reference that contains two or more views of the same dosage form of the product; in most cases this should represent front and back views of the dosage form, but occasionally additional views might be needed in order to capture all of the important physical characteristics of the dosage form.  Any imprint and/or symbol should be clearly identifiable, and the viewer should not normally need to rotate the image in order to read it.  Images that are submitted with SPL should be included in the same directory as the SPL file.


code: ACPROV

display: provider information access

definition: Description: Provide consent to collect, use, disclose, or access provider information for a patient.


code: CPNDDRGING

display: compound drug invoice group

definition: A grouping of invoice element groups and details including the ones specifying the compound ingredients being invoiced. It may also contain generic detail items such as markup.


code: AE

display: American Express

definition: American Express


code: PRVTRN

display: private transport

definition: private transport


code: FFPS

display: first fill, part fill, partial strength

definition: A first fill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.) and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets)


definition: Description: Reporting codes that are related to an immunization event.


code: ADNFPPELAT

display: adjud. nullified prior-period electronic amount

definition: Identifies the total net amount of all  Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.


code: SPLCOATING

display: coating

definition:
Definition: A characteristic of an oral solid dosage form of a medicinal product, indicating whether it has one or more coatings such as sugar coating, film coating, or enteric coating.  Only coatings to the external surface or the dosage form should be considered (for example, coatings to individual pellets or granules inside a capsule or tablet are excluded from consideration).

                           Constraints: The Observation.value must be a Boolean (BL) with true for the presence or false for the absence of one or more coatings on a solid dosage form.


code: OINT

display: intolerance

definition: Hypersensitivity resulting in an adverse reaction upon exposure to an agent.


definition: Identifies the type of observation that is made about a specimen that may affect its processing, analysis or further result interpretation

display: ActSpecObsCode


code: ADNFSPMNAT

display: adjud. nullified same-period manual amount

definition: Identifies the total net amount of all  Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.


display: ImmunizationObservationType

definition: Description: Observation codes which describe characteristics of the immunization material.


code: COVGE

display: coverage problem

definition: Insurance coverage problems have been encountered. Additional explanation information to be supplied.


display: prior therapy documented

definition: Description: It has been confirmed that the appropriate pre-requisite therapy has been tried.


code: CREACT

display: common reaction alert

definition:
Description:Proposed therapy may be inappropriate or contraindicated because of a common but non-patient specific reaction to the product.

                           Example:There is no record of a specific sensitivity for the patient, but the presence of the sensitivity is common and therefore caution is warranted.


code: ACOBS

display: common observations access

definition: Description: Provide consent to collect, use, disclose, or access common observation information for a patient.


code: RFPS

display: refill part fill partial strength

definition: A refill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.) and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).

hierarchy: _ActPharmacySupplyType RF RFP


code: CPTM

display: CPT modifier codes

definition: Description:CPT modifier codes are found in Appendix A of CPT 2000 Standard Edition.


code: ONET

display: one time

definition: Definition:A list of medications which the patient is intended to be administered only once.


display: vaccine product problem

definition: Indicates that the ICSR is describing a problem with the actual vaccine product such as physical defects (cloudy, particulate matter) or inability to confer immunity.


code: INFPWR

display: only if public welfare risk

definition: Authorization to collect, access, use, or disclose specified patient health information necessary to avert potential public welfare risk in accordance with jurisdictional law, organizational policy, or standards of practice.  For example, reporting that a person is a victim of abuse or demonstrating suicidal tendencies.


code: RENT

display: Rent

definition: Temporary supply of a product with financial compensation, without transfer of ownership for the product.


code: CWOH

display: certified women's health care

definition: Description:Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.


code: OPTINR

display: opt-in with restrictions

definition:
A grantor's assent to the grantee's terms of an agreement with an opportunity for to dissent to certain grantor or grantee selected terms.

                           Comment: A grantor dissenting to the grantee's terms of agreement may or may not exercise a right to assent to grantor's pre-approved restrictions or to grantee's selected terms to which a grantor may dissent.

                           Usage Note: Opt-in with restrictions is considered "granular consent" because the grantor has an opportunity to narrow the permissions sought by the grantee.

                           Examples:

                           Healthcare:  A patient assent to grantee's consent directive terms for collection, access, use, or disclosure of health information, and dissents to disclosure to certain recipients as allowed by the provider's pre-approved restriction list.
                           Non-Healthcare: A cell phone user assents to the cell phone's privacy practices and terms of use, but dissents from location tracking by turning off the cell phone's tracking capability.


code: CMPMSRMTH

display: composite measure method

definition: Indicates what method is used in a quality measure to combine the component measure results included in an composite measure.


definition: Definition: Codes representing the maximum coverate or financial participation requirements.

child: LFEMX PRDMX

code: COVMX

display: coverage maximum


code: DOSEIVLIND

display: Dose-Interval for Indication Alert

definition: Proposed dosage interval/timing differs from standard practice for the identified indication or diagnosis


code: MASK

display: mask

definition: Custodian system must render information unreadable and unusable by algorithmically transforming plaintext into ciphertext.  User may be provided a key to decrypt per license or "shared secret".


code: FNLFEE

display: final fee

definition: Anticipated or actual final fee associated with treating a patient.


code: REL

display: religion information sensitivity

definition:
Policy for handling information related to an information subject's religious affiliation, which will be afforded heightened confidentiality.  Policies may govern sensitivity of information related to an information subject's religion, the disclosure of which could impact the privacy, well-being, or safety of that subject.

                           Usage Notes: If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


code: RINT

display: Related Intolerance Alert

definition: Proposed therapy may be inappropriate or contraindicated because of a recorded patient intolerance to a cross-sensitivity related product.  (Intolerances are non-immune based sensitivities.)


code: RFCS

display: refill complete partial strength

definition: A refill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets.) and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).

hierarchy: _ActPharmacySupplyType RF RFC


code: IMMLREV

display: immunization list review

definition: Description: A person reviews a list of immunizations due or received for a given patient.


code: AIRTRNS

display: airborne transmission

definition: Communication of an agent from a living subject or environmental source to a living subject through indirect contact via oral or nasal inhalation.


code: TRSTCERTOBS

display: trust certificate observation

definition:
Type of security metadata observation made about a set of security-relevant data issued by a security authority or trusted third party, together with security information which is used to provide the integrity and data origin authentication services for an IT resource (data, information object, service, or system capability). [Based on ISO IEC 10181-1]

                           For example,

                           A Certificate Policy (CP), which is a named set of rules that indicates the applicability of a certificate to a particular community and/or class of application with common security requirements. For example, a particular Certificate Policy might indicate the applicability of a type of certificate to the authentication of electronic data interchange transactions for the trading of goods within a given price range. [Trust Service Principles and Criteria for Certification Authorities Version 2.0 March 2011 Copyright 2011 by Canadian Institute of Chartered Accountants.
                           A Certificate Practice Statement (CSP), which is a statement of the practices which an Authority employs in issuing and managing certificates. [Trust Service Principles and Criteria for Certification Authorities Version 2.0 March 2011 Copyright 2011 by Canadian Institute of Chartered Accountants.]

hierarchy: SECOBS SECTRSTOBS


code: INITIMMUNIZ

display: Initial Immunization

definition: The first immunization administration in a series intended to produce immunity


code: NAT

display: Insufficient authorization

definition: The requesting party has insufficient authorization to invoke the interaction.


code: MLREV

display: medication list review task

definition: A person reviews a list of medication orders submitted to a given patient


code: AOSC

display: accredited office-based surgery care

definition: Description:Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.


code: DISEASEPRG

display: public health program

definition:
Definition: A public or government health program that administers and funds coverage for health and social services to assist program eligible who meet financial and health status criteria related to a particular disease.

                           Example: Reproductive health, sexually transmitted disease, and end renal disease programs.


code: DOSELINDW

display: Low Dose for Weight Alert

definition: Proposed dosage is below suggested therapeutic levels for the patient's weight


display: ActCoverageTypeCode

definition: Definition: Set of codes indicating the type of insurance policy or program that pays for the cost of benefits provided to covered parties.


code: RESEARCH

display: research information access

definition: Definition: Consent to have healthcare information in an electronic health record accessed for research purposes.


code: PDNFSPMNAT

display: paid nullified same-period manual amount

definition: Identifies the total net amount of all  Invoice Groupings that were paid during the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.


code: PAY

display: payment

definition: The guarantor, who may be the patient, pays the entire charge for a service. Reasons for such action may include: there is no insurance coverage for the service (e.g. cosmetic surgery); the patient wishes to self-pay for the service; or the insurer denies payment for the service due to contractual provisions such as the need for prior authorization.


code: WIATTCH

display: work injury report attachment

definition: Description: Work Injury related additional Information Attachment


code: RFC

display: Refill - Complete

definition: A refill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets.)


code: OTC

display: non prescription medicine

definition: Medicines designated in this way may be supplied for patient use without a prescription.  The exact form of categorisation will vary in different realms.


code: RSREID

display: re-identifiable information access

definition:
Definition: Consent to have de-identified healthcare information in an electronic health record that is accessed for research purposes re-identified under specific circumstances outlined in the consent.

                           Example:: Where there is a need to inform the subject of potential health issues.


code: CART

display: Cart - patient travels on cart or gurney

de: Patient wird auf Trage transportiert

nl: Wagentje - patiënt reist per karretje of ziekenhuisbed


code: PORT

display: The examining device goes to patient's location

de: Untersuchung am Krankenbett

nl: Het onderzoeksapparaat gaat naar de patiëntlocatie


code: WALK

display: Patient walks to diagnostic service

de: Patient geht zu Fuß zum Funktionsbereich

nl: Patiënt loopt naar diagnostische service


code: medical-device-use-error

display: Medical Device Use Error

definition: The adverse event pertains to a medical device use error.


code: wrong-time

display: Wrong Time

definition: The adverse event pertains to a wrong time.


code: wrong-dose

display: Wrong Dose

definition: The adverse event pertains to a wrong dose.


code: wrong-rate

display: Wrong Rate

definition: The adverse event pertains to a wrong rate.


code: problem-different-manufacturer

display: Problem with Different Manufacturer of Same Medicine

definition: The adverse event pertains to a problem with a different manufacturer of the same medication.


code: product-use-error

display: Product Use Error

definition: The adverse event pertains to a product use error.


code: wrong-duration

display: Wrong Duration

definition: The adverse event pertains to a wrong duration.


code: incorrect-prescribing-information

display: Incorrect Prescribing Information

definition: The adverse event pertains to incorrect perscribing information.


code: product-quality

display: Product Quality

definition: The adverse event pertains to product quality.


code: expired-drug

display: Expired Drug

definition: The adverse event pertains to an expired drug.


code: unsafe-physical-environment

display: Unsafe Physical Environment

definition: The adverse event pertains to an unsafe physical environment.


code: wrong-route-of-administration

display: Wrong Route of Administration

definition: The adverse event pertains to a wrong route of administration.


code: product-problem

display: Product Problem

definition: The adverse event pertains to a product problem.


code: wrong-technique

display: Wrong Technique

definition: The adverse event pertains to a wrong technique.


code: DEF

display: definition

definition:
Definition: A definition of a kind of act that can occur .

                           OpenIssue: The semantic constructs embodied in DEF and CRT moods seem indistinguishable, and their uses can readily be determined by the context in which these are used. Therefore, this OpenIssue has been created to declare that it is likely that ActMood.DEF will be "retired" in the future in favor of the more general ActMood.CRT.


definition:
Definition: A request (or order) for an act that is part of a defined request/fulfillment cycle.

                           UsageNotes: Use of an HL7 defined request/fulfillment framework is not required to use this mood code.

display: act request


code: RQO

display: request

definition:
Definition: A request act that is specialized for an event request/fulfillment cycle.

                           UsageNotes: The fulfillment cycle may involve intermediary fulfilling acts in moods such as PRMS, APT, or even another RQO before being fulfilled by the final event.

                           UsageNotes: The concepts of a "request" and an "order" are viewed as different, because there is an implication of a mandate associated with order.  In practice, however, this distinction has no general functional value in the inter-operation of health care computing.  "Orders" are commonly refused for a variety of clinical and business reasons, and the notion of a "request" obligates the recipient (the fulfiller) to respond to the sender (the author).  Indeed, in many regions, including Australia and Europe, the common term used is "request."

                        Thus, the concept embodies both notions, as there is no useful distinction to be made.  If a mandate is to be associated with a request, this will be embodied in the "local" business rules applied to the transactions.  Should HL7 desire to provide a distinction between these in the future, the individual concepts could be added as specializations of this concept.

                        The critical distinction here, is the difference between this concept and an "intent", of which it is a specialization.  An intent involves decisions by a single party, the author.  A request, however, involves decisions by two parties, the author and the fulfiller, with an obligation on the part of the fulfiller to respond to the request indicating that the fulfiller will indeed fulfill the request.


code: RSK

display: risk

definition:
Definition:An act that may occur in the future and which is regarded as undesirable

                           Examples:Increased risk of DVT, at risk for sub-acute bacterial endocarditis.

                           UsageNotes:Note: An observation in RSK mood expresses the undesirable act, and not the underlying risk factor. A risk factor that is present (e.g. obesity, smoking, etc) should be expressed in event mood. INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with RSK (risk), which is the potential that something negative will occur that may or may not ever happen. GOL (goal) reflects a hope to achieve something. EXPEC (expectation) is the prediction of a positive or negative event. This contrasts with RSK (risk), which is the potential that something negative will occur that may or may not ever happen, and may not be expected to happen.


code: ARQ

display: appointment request

definition: Definition: A request act that is specialized for the appointment scheduling request/fulfillment cycle. An appointment request is fulfilled only and completely by an appointment (APT), i.e., all that the appointment request intends is to create an appointment (the actual act may well not happen if that is the professional decision during the appointment).


display: ActMoodPredicate

definition: Definition: An act that expresses condition statements for other acts.


definition: Definition:  A desire to have an act occur.

display: desire


display: request criterion

definition: A criterion expressed over requests or orders (ActMood.RQO).


code: SLOT

display: resource slot

definition: Definition: A kind of act that may occur during the specified time period.


definition:
Deprecation Comment:
                           This concept This codes should no longer be used.  Instead, set attribute Act.isCriterionInd to "true" and use the desired mood for your criterion.

                           Definition: A condition that must be true for the source act to be considered.

code: CRT

display: criterion


display: ActMoodCompletionTrack

definition: These are moods describing activities as they progress in the business cycle, from defined, through planned and ordered to completed.


code: EVN

display: event (occurrence)

definition: Definition: An act that actually happens (may be an ongoing act or a documentation of a past act).


code: PRMS

display: promise

definition:
Definition: A commitment to perform an act (may be either solicited or unsolicited). The committer becomes responsible to the other party for executing the act, and, as a consequence, the other party may rely on the first party to perform or cause to perform the act.

                           UsageNotes: Commitments may be retracted or cancelled.


code: RMD

display: recommendation

definition:
Definition: A suggestion that an act should be performed with an acceptance of some degree of professional responsibility for the resulting act. Not an explicit request. .

                           UsageNotes: Where there is no clear definition or applicable concept of "professional responsibilityâ€?, RMD becomes indistinguishable from PRP. .


code: INT

display: intent

definition:
Definition: An intention or plan for an act.

                           >UsageNotes: The final outcome of the intent, the act that is intended to occur, is always an event. However the final outcome may be reached indirectly via steps through other intents, such as promise, permission request, or an appointment that may lead to an actual event to occur. Alternatively, the intended act may never occur.


code: PERMRQ

display: permission request

definition: Definition: A request for a permission to perform the act. Typically a payer (or possibly a supervisor) is being requested to give permission to perform the act. As opposed to the RQO, the requestee is not asked to perform or cause to perform the act but only to give the permission.


definition: Definition: A possible act.

display: potential


code: EXPEC

display: expectation

definition:
Definition: An act that is considered to have some noteworthy likelihood of occurring in the future (has_match = event).

                           Examples:Prognosis of a condition, Expected date of discharge from hospital, patient will likely need an emergency decompression of the intracranial pressure by morning.

                           UsageNotes:INT (intent) reflects a plan for the future, which is a declaration to do something. This contrasts with expectation, which is a prediction that something will happen in the future. GOL (goal) reflects a hope rather than a prediction. RSK (risk) reflects a potential negative event that may or may not be expected to happen.


display: promise criterion

definition: A criterion expressed over promises (ActMood.PRMS).


code: OPT

display: option

definition: Definition: One of a set of acts that specify an option for the property values that the parent act may have. Typically used in definitions or orders to describe alternatives. An option can only be used as a group, that is, all assigned values must be used together. The actual mood of the act is the same as the parent act, and they must be linked by an actrelationship with type = OPTN.


code: PRP

display: proposal

definition: Definition: A suggestion that an act might be performed. Not an explicit request, and professional responsibility may or may not be present.


code: PERM

display: permission

definition: Definition: A kind of act that defines a permission that has been granted.


definition:
Deprecation Comment:
                           This concept This codes should no longer be used.  Instead, set attribute Act.isCriterionInd to "true" and use the desired mood for your criterion.

                           Definition: A criterion (CRT) that has_match = an event (EVN).

display: event criterion


code: APT

display: appointment

definition: Definition: An act that has been scheduled to be performed at a specific place and time.

hierarchy: _ActMoodCompletionTrack INT PRMS


display: intent criterion

definition: A criterion expressed over intents (ActMood.INT).


display: goal criterion

definition: A criterion expressed over goals (ActMood.GOL).


display: risk criterion

definition: A criterion expressed over risks (ActMood.RSK).


code: GOL

display: Goal

definition:
Definition: An expectation that is considered to be desirable to occur in the future

                           Examples:Target weight below 80Kg, Stop smoking, Regain ability to walk, goal is to administer thrombolytics to candidate patients presenting with acute myocardial infarction.

                           UsageNotes: INT (intent) reflects a plan for the future, which is a declaration to do something.  This contrasts with goal which doesn't represent an intention to act, merely a hope for an eventual result.  A goal is distinct from the intended actions to reach that goal.  "I will reduce the dose of drug x to 20mg" is an intent.  "I hope to be able to get the patient to the point where I can reduce the dose of drug x to 20mg" is a goal. EXPEC (expectation) reflects a prediction rather than a hope. RSK (risk) reflects a potential negative event rather than a hope.


display: Anatomic Pathology Structured Report Cancer Ovary


display: HL7 CCD Document

valueset: endpoint-payload-type


display: For documents following C-CDA constraints using a non structured body.


display: Anatomic Pathology Structured Report Cancer Endometrium


display: Anatomic Pathology Structured Report All


code: urn:ihe:pat:apsr:cancer:esophagus: 2010

display: Anatomic Pathology Structured Report Cancer Esophagus


display: Anatomic Pathology Structured Report Cancer Lung


display: Anatomic Pathology Structured Report Cancer Kidney


display: Anatomic Pathology Structured Report Cancer Skin


display: Anatomic Pathology Structured Report Cancer Testis


display: History and Physical Specification


display: PDF embedded in CDA per XDS-SD profile


display: For documents following C-CDA constraints using a structured body.


display: Anatomic Pathology Structured Report Cancer Breast


display: Anatomic Pathology Structured Report Cancer Cervix


display: Anatomic Pathology Structured Report Cancer Urinary Bladder


code: urn:ihe:pat:apsr:cancer:stomach: 2010

display: Anatomic Pathology Structured Report Cancer Stomach


display: Text embedded in CDA per XDS-SD profile


display: Emergency Department Referral (EDR)


display: Anatomic Pathology Structured Report Cancer Prostate


display: Anatomic Pathology Structured Report Cancer All


display: Antepartum Record (APR) - History and Physical


display: Anatomic Pathology Structured Report Cancer Liver


display: Immunization Registry Content (IRC)


display: Emergency Department Encounter Summary (EDES)


display: Anatomic Pathology Structured Report Cancer Pharynx


display: Anatomic Pathology Structured Report Cancer Thyroid


display: Antepartum Record (APR) - Education


display: Basic Patient Privacy Consents with Scanned Document


display: Anatomic Pathology Structured Report Cancer Lip Oral Cavity


display: Anatomic Pathology Structured Report Cancer Colon


code: urn:ihe:pat:apsr:cancer:pancreas: 2010

display: Anatomic Pathology Structured Report Cancer Pancreas


display: Anatomic Pathology Structured Report Cancer Salivary Gland


display: Antepartum Record (APR) - Laboratory


display: Anatomic Pathology Structured Report Cancer Larynx


code: O

display: Order plus order status

de: Auftrag und Auftragsstatus

nl: Aanvraag plus aanvragstatus


code: R

display: Results without bulk text

de: Ergebnisse / Befunde ohne umfänglichen Text

nl: Resultaten zonder bulktest


code: S

display: Status only

de: nur Statusinformation

nl: Alleen status


code: T

display: Full results

de: Komplette Ergebnisse / Befunde

nl: Volledige resultaten


code: usual

display: Usual

definition: The identifier recommended for display and use in real-world interactions.


code: official

display: Official

definition: The identifier considered to be most trusted for the identification of this item. Sometimes also known as "primary" and "main". The determination of "official" is subjective and implementation guides often provide additional guidelines for use.


code: secondary

display: Secondary

definition: An identifier that was assigned in secondary use - it serves to identify the object in a relative context, but cannot be consistently assigned to the same object again in a different context.


code: old

display: Old

definition: The identifier id no longer considered valid, but may be relevant for search purposes.  E.g. Changes to identifier schemes, account merges, etc.


display: Unsupported event code

de: Ereignis wird nicht unterstützt

nl: Niet-ondersteunde eventcode


display: Unsupported processing id

de: Processing-ID wird nicht unterstützt

nl: Niet-ondersteunde processing id


display: Application error

de: applikationsinterner Fehler

nl: Interne applicatiefout


display: Required field missing

de: erforderliches Feld leer

nl: Verplicht veld ontbreekt


display: Unsupported version id

de: Version wird nicht unterstützt

nl: Niet-ondersteunde versie


display: Segment sequence error

de: Fehler in der Segmentreihenfolge

nl: Fout in segmentvolgorde


display: Unsupported message type

de: Nachrichtentyp wird nicht unterstützt

nl: Niet-ondersteund berichttype


display: Duplicate key identifier

de: doppelter Schlüsselwert

nl: Duplicaat sleutel-identificatie


display: Application record locked

de: Datensatz durch Applikation gesperrt

nl: Applicatie record vergrendeld


display: Message accepted

de: Nachricht akzeptiert

nl: Bericht geaccepteerd


display: Data type error

de: Datentypfehler

nl: Fout in datatype


display: Unknown key identifier

de: Schlüsselwert nicht gefunden

nl: Onbekende sleutel-identificatie


display: Table value not found

de: fehlender Eintrag in der Tabelle

nl: Tabelwaarde niet gevonden


code: ABC

display: Alphabetic

definition: Alphabetic transcription of name (Japanese: romaji)


code: SRCH

display: search

definition: A name intended for use in searching or matching.


code: L

display: Legal

definition: Known as/conventional/the one you use


code: IDE

display: Ideographic

definition: Ideographic representation of name (e.g., Japanese kanji, Chinese characters)


code: SNDX

display: Soundex

definition: A name spelled according to the SoundEx algorithm.


code: PHON

display: phonetic

definition:
A name spelled phonetically.

                        There are a variety of phonetic spelling algorithms. This code value does not distinguish between these.Discussion:


display: Religious

definition: e.g. Sister Mary Francis, Brother John


code: C

display: License

definition: As recorded on a license, record, certificate, etc. (only if different from legal name)


code: ASGN

display: assigned

definition: A name assigned to a person. Reasons some organizations assign alternate names may include not knowing the person's name, or to maintain anonymity. Some, but not necessarily all, of the name types that people call "alias" may fit into this category.


display: NameRepresentationUse

definition: Identifies the different representations of a name.  The representation may affect how the name is used.  (E.g. use of Ideographic for formal communications.)


code: P

display: pseudonym

definition: A self asserted name that the person is using or has used.


code: SYL

display: Syllabic

definition: Syllabic transcription of name (e.g., Japanese kana, Korean hangul)


code: A

display: Artist/Stage

definition: Includes writer's pseudonym, stage name, etc


code: OR

display: official registry

definition: Definition:The formal name as registered in an official (government) registry, but which name might not be commonly used. Particularly used in countries with a law system based on Napoleonic law.


code: I

display: Indigenous/Tribal

definition: e.g. Chief Red Cloud


code: medication

display: Medication

definition: Supply is a kind of medication.


code: device

display: Device

definition: What is supplied (or requested) is a device.


code: directlink

display: Click and see

definition: When URL is clicked, the resource can be seen directly (by webpage or by download link format).


code: openapi

display: The URL is the RESTful or other kind of API that can access to the result.

definition: When the API method (e.g. [base_url]/[parameter]) related with the URL of the website is executed, the resource can be seen directly (usually in JSON or XML format).


code: login

display: Result cannot be access unless an account is logged in

definition: When logged into the website, the resource can be seen.


code: oauth

display: Result need to be fetched with API and need LOGIN( or cookies are required when visiting the link of resource)

definition: When logged in and  follow the API in the website related with URL, the resource can be seen.


code: other

display: Some other complicated or particular way to get resource from URL.


code: RBC

display: Erythrocytes

de: Erythrozyten

nl: Erythrocyten


code: SPTT

display: Sputum - tracheal aspirate

de: Sputum - tracheal aspiriert

nl: Sputum - tracheaal aspiraat


code: MILK

display: Breast milk

de: Brustmilch

nl: Borstmelk


code: BPU

display: Blood product unit

nl: Bloedproduct eenheid


code: EOS

display: Eosinophils

de: Eosinophile

nl: Eosinofiel


code: THRB

display: Thrombocyte (platelet)

de: Thrombozyten

nl: Trombocyt (platelet)


code: IT

display: Intubation tube

de: Tubus

nl: Intubatieslang


code: URC

display: Urine clean catch

de: Mittelstrahlurin

nl: Urine midstream


code: UMED

display: Unknown medicine

de: unbekannte Medizin

nl: Onbekende medicatie


code: STL

display: Stool = Fecal

de: Stuhl

nl: Ontlasting = Feces


code: SEM

display: Seminal fluid

de: Sperma

nl: Seminaal vocht


code: BLDA

display: Blood  arterial

de: arterielles Blut

nl: Arterieel bloed


code: CDM

display: Cardiac muscle

de: Herzmuskel

nl: Hartspier


code: MN

display: Amniotic Fluid

de: Fruchtwasser

nl: Amniotisch vocht


code: MBLD

display: Menstrual blood

de: Menstruationsblut

nl: Menstruatiebloed


code: GENC

display: Genital cervix

de: Genitale - Cervix

nl: Genitaal cervix


code: RT

display: Route of medicine

nl: Route van zorg


code: LIQ

display: Liquid NOS

nl: Vloeistof, niet anders gespecificeerd


code: GENV

display: Genital vaginal

de: Genitale - Vagina

nl: Genitaal vaginaal


code: BLD

display: Whole blood

de: Gesamtes Blut

nl: Geheel bloed


code: TLGI

display: Tissue large intestine

nl: Weefsel groot intestinaal


code: PLR

display: Pleural fluid (thoracentesis fld)

de: Pleuraflüssigkeit (nach Thoracocentese)

nl: Pleuraal vocht (thoracentesis vocht)


code: XXX

display: To be specified in another part of the message

nl: Wordt gespecificeerd in een ander deel van het bericht


code: PLB

display: Plasma bag

de: Plasmabeutel

nl: Plasmazak


code: MAC

display: Macrophages

de: Makrophagen

nl: Macrofagen


code: LNV

display: Line venous

de: Venöser Zugang

nl: Veneuze lijn


code: NOS

display: Nose (nasal passage)

de: Nase (Nasenwege)

nl: Neus (nasale doorgang)


code: CTP

display: Catheter tip

de: Katheterspitze

nl: Catether tip


code: USUB

display: Unknown substance

nl: Onbekende substantie


code: SKM

display: Skeletal muscle

de: Skelettmuskel

nl: Skeletspier


code: BRTH

display: Breath (use EXHLD)

de: Atemluft

nl: Adem (gebruik EXHLD)


code: TISPL

display: Tissue placenta

de: Placentagewebe

nl: Weefsel placenta


code: CALC

display: Calculus (=Stone)

de: Steinchen, Konkrement

nl: Calculus (=Steen)


code: PRT

display: Peritoneal fluid /ascites

de: Peritonealflüssigkeit / Ascites

nl: Peritoneaal vocht / ascites


code: CBLD

display: Cord blood

de: Nabelschnurblut

nl: Streng bloed


code: LYM

display: Lymphocytes

de: Lymphozyten

nl: Lymfocyten


code: ENDM

display: Endometrium

de: Endometrium

nl: Endometrium


code: BLDCO


code: GENL

display: Genital lochia

de: Wochenfluß / Lochien

nl: Genitaal lochia


code: BDY

display: Whole body

de: Gesamter Körper

nl: Geheel lichaam


code: ABLD

display: Arterial blood

de: Arterielles Blut

nl: Arterieel bloed


code: PMN

display: Polymorphonuclear neutrophils

de: Polymorphkernige Neutrophile

nl: Polymorfonucleaire neutrofielen


code: TISG

display: Tissue gall bladder

de: Gallenblasengewebe

nl: Weefsel galblaas


code: WNDD

display: Wound drainage

de: Wunddrainage

nl: Wond drainage


code: EXHLD

display: Exhaled gas (=breath)

nl: Uitgeademde lucht (=adem)


code: SPTC

display: Sputum - coughed

de: Sputum - Hustenauswurf

nl: Sputum - gehoest


code: DUFL

display: Duodenal fluid

nl: Duodenaal vocht


code: IHG

display: Inhaled Gas

de: inhaliertes Gas

nl: Geïnhaleerde lucht


code: PPP

display: Platelet poor plasma

nl: Patelet-arm plasma


code: TSMI

display: Tissue small intestine

nl: Weefsel klein intestinaal


code: STON

display: Stone (use CALC)

de: Steine

nl: Steen (gebruik CALC)


code: CUR

display: Curettage

de: Curettagematerial

nl: Curettage


code: WBC

display: Leukocytes

de: Leukozyten

nl: Leukocyten


code: AMN

display: Amniotic fluid

de: Fruchtwasser

nl: Amniotisch vocht


code: URT

display: Urine catheter

de: Katheterurin

nl: Urine catether


code: DOSE

display: Dose med or substance

nl: Medicatie of substantie


code: EXG


code: TISU

display: Tissue ulcer

de: Ulcusgewebe

nl: Weefsel maagzweer


code: TISL

display: Tissue lung

de: Lungengewebe

nl: Weefsel long


code: CNJT

display: Conjunctiva

de: Konjunktiven

nl: Conjunctiva


code: TISB

display: Tissue bone marrow

de: Knochenmarksgewebe

nl: Weefsel beenmerg


code: PER

display: Peritoneum

de: Peritoneum

nl: Peritoneum


code: SPRM

display: Spermatozoa

de: Spermien

nl: Spermatozoïden


code: BLDV

display: Blood  venous

de: venöses Blut

nl: Veneus bloed


code: WICK

display: Wick

de: Zwischengefäß bei Infusoren (?)

nl: Lont


code: FLU

display: Body fluid, unsp

de: Körperflüssigkeit (unspezifiziert)

nl: Lichaamsvocht, niet-gesp


code: CSF

display: Cerebral spinal fluid

de: Cerebralflüssigkeit

nl: Hersenvocht


code: WNDA

display: Wound abscess

de: Wundabszeß

nl: Wondabces


code: EARW

display: Ear wax (cerumen)

nl: Oorsmeer (cerumen)


code: PRP

display: Platelet rich plasma

nl: Patelet-rijk plasma


code: TISC

display: Tissue curettage

de: Kürettagegewebe

nl: Weefsel curettage


code: TUB

display: Tube NOS

nl: Slang, niet anders gespecificeerd


code: WNDE

display: Wound exudate

de: Wundexsudat

nl: Wond exsudaat


code: BRO

display: Bronchial

de: Bronchialwege

nl: Bronchiaal


code: GAST

display: Gastric fluid/contents

de: Magenflüssigkeit

nl: Maagvocht/inhoud


code: SNV

display: Synovial fluid (Joint fluid)

de: Synovialflüssigkeit

nl: Synoviaal vocht (gewrichtvocht)


code: CVM

display: Cervical mucus

de: Cervicalschleim

nl: Cervicale mucus


code: ASP

display: Aspirate

de: Aspirationssubstrat

nl: Aspiraat


code: LNA

display: Line arterial

de: Arterieller Zugang

nl: Arteriële lijn


code: TISP

display: Tissue peritoneum

de: Peritonealgewebe

nl: Weefsel peritoneum


code: FIB

display: Fibroblasts

de: Fibroblasten

nl: Fibroblasts


code: COL

display: Colostrum

de: Kolostrum, Vormilch

nl: Colostrum


code: UMB

display: Umbilical blood

de: Nabelblut

nl: Navelstreng bloed


code: ENDC

display: Endocardium

de: Endocard

nl: Endocardium


code: BLDC

display: Blood  capillary

de: Kapillarblut

nl: Capillair bloed


code: PAFL

display: Pancreatic fluid

nl: Pancreas vocht


code: species

display: Species

definition: The species to which an artifact applies. For example, SNOMED - 387961004 | Kingdom Animalia (organism).


code: age

display: Age Range

definition: The age of the patient. For this context type, the value could be a range that specifies the applicable ages or a code from an appropriate value set such as the MeSH value set http://terminology.hl7.org/ValueSet/v3-AgeGroupObservationValue.


code: user

display: User Type

definition: The clinical specialty of the context in which the patient is being treated - For example, PCP, Patient, Cardiologist, Behavioral Professional, Oral Health Professional, Prescriber, etc... taken from a specialty value set such as the NUCC Health Care provider taxonomy value set http://hl7.org/fhir/ValueSet/provider-taxonomy.


code: focus

display: Clinical Focus

definition: The clinical concept(s) addressed by the artifact. For example, disease, diagnostic test interpretation, medication ordering as in http://hl7.org/fhir/ValueSet/condition-code.


code: gender

display: Gender

definition: The gender of the patient. For this context type, appropriate values can be found in the http://hl7.org/fhir/ValueSet/administrative-gender value set.


code: workflow

display: Workflow Setting

definition: The settings in which the artifact is intended for use. For example, admission, pre-op, etc. For example, the ActEncounterCode value set http://terminology.hl7.org/ValueSet/v3-ActEncounterCode.


code: venue

display: Clinical Venue

definition: The venue in which an artifact could be used. For example, Outpatient, Inpatient, Home, Nursing home. The code value may originate from the HL7 ServiceDeliveryLocationRoleType value set (http://terminology.hl7.org/ValueSet/v3-ServiceDeliveryLocationRoleType).


code: task

display: Workflow Task

definition: The context for the clinical task(s) represented by this artifact. For example, this could be any task context represented by the HL7 ActTaskCode value set http://terminology.hl7.org/ValueSet/v3-ActTaskCode. General categories include: order entry, patient documentation and patient information review.


code: program

display: Program

definition: A program/project of work for which this artifact is applicable.


code: RA

display: Returned unused/no longer needed


code: RL

display: Returned unused/keep linked to patient for possible use later


code: TR

display: Transfused with adverse reaction


code: WA

display: Wasted (product no longer viable)


code: retired

display: Retired

definition: Retired persons have all copays and deductibles reduced.


code: foster

display: Foster child

definition: Children in the foster care have all copays and deductibles waived.


code: collect

display: Collect

definition: Gather retrieved information for storage


code: access

display: Access

definition: Retrieval without permitting collection, use or disclosure. e.g., no screen-scraping for collection, use or disclosure (view-only access)


code: use

display: Use

definition: Utilize the retrieved information


code: disclose

display: Disclose

definition: Transfer retrieved information


code: correct

display: Access and Correct

definition: Allow retrieval of a patient's information for the purpose of update or rectify


code: next

display: next

definition: Refers to the next document in a linear sequence of documents. User agents may choose to preload the "next" document, to reduce the perceived load time.


code: index

display: index

definition: Refers to a document providing an index for the current document.


code: appendix

display: appendix

definition: Refers to a document serving as an appendix in a collection of documents.


code: subsection

display: subsection

definition: Refers to a document serving as a subsection in a collection of documents.


code: stylesheet

display: stylesheet

definition: Refers to an external style sheet. See the section on external style sheets for details. This is used together with the link type "Alternate" for user-selectable alternate style sheets.


code: section

display: section

definition: Refers to a document serving as a section in a collection of documents.


code: bookmark

display: bookmark

definition: Refers to a bookmark. A bookmark is a link to a key entry point within an extended document. The title attribute may be used, for example, to label the bookmark. Note that several bookmarks may be defined in each document.


code: contents

display: contents

definition: Refers to a document serving as a table of contents. Some user agents also support the synonym ToC (from "Table of Contents").


code: start

display: start

definition: Refers to the first document in a collection of documents. This link type tells search engines which document is considered by the author to be the starting point of the collection.


code: prev

display: prev

definition: Refers to the previous document in an ordered series of documents. Some user agents also support the synonym "Previous".


code: copyright

display: copyright

definition: Refers to a copyright statement for the current document.


code: help

display: help

definition: Refers to a document offering help (more information, links to other sources of information, etc.).


code: alternate

display: alternate

definition: Designates substitute versions for the document in which the link occurs. When used together with the lang attribute, it implies a translated version of the document. When used together with the media attribute, it implies a version designed for a different medium (or media).


code: glossary

display: glossary

definition: Refers to a document providing a glossary of terms that pertain to the current document.


code: chapter

display: chapter

definition: Refers to a document serving as a chapter in a collection of documents.


display: use NUBC codes

nl: Zie (Amerikaanse) NUBC codes


code: AA

display: Original mode: Application Accept - Enhanced mode: Application acknowledgment: Accept

de: akzeptiert durch Anwendung

nl: Original modus: Applicatiebevestiging - Enhanced modus: Applicatiebevestiging: accepteer


code: AE

display: Original mode: Application Error - Enhanced mode: Application acknowledgment: Error

de: Fehler in Anwendung

nl: Original modus: Applicatiefout - Enhanced modus: Applicatiebevestiging: fout


code: AR

display: Original mode: Application Reject - Enhanced mode: Application acknowledgment: Reject

de: Abgelehnt durch Anwendung

nl: Original modus: Applicatieweigering - Enhanced modus: Applicatiebevestiging: weiger


code: CA

display: Enhanced mode: Accept acknowledgment: Commit Accept

de: Bei Eingangsprüfung akzeptiert ("committed")

nl: Enhanced modus: Ontvangstbevestiging: accepteer ontvangst


code: CE

display: Enhanced mode: Accept acknowledgment: Commit Error

de: Fehler bei Eingangsprüfung

nl: Enhanced modus: Ontvangstbevestiging: fout in ontvangst


code: CR

display: Enhanced mode: Accept acknowledgment: Commit Reject

de: Bei Eingangsprüfung abgelehnt

nl: Enhanced modus: Ontvangstbevestiging: weigering te ontvangen


code: pharmacy-dispense

display: Pharmacy Dispense Coverage

definition: Pharmacy Dispense Coverage


code: copay

display: Copayment per service

definition: Copayment per service


code: deductible

display: Deductible

definition: Cost to be incurred before benefits are applied


code: copay-maximum

display: Copayment maximum per service

definition: Copayment maximum per service


code: vision-exam

display: Vision Exam

definition: Vision Exam


code: vision-contacts

display: Vision Contacts Coverage

definition: Contact Lenses


code: vision-glasses

display: Vision Glasses

definition: Frames and lenses


code: medical-primarycare

display: Medical Primary Health Coverage

definition: Medical Primary Health Coverage


code: benefit

display: Benefit

definition: Maximum benefit allowable.


code: copay-percent

display: Copayment Percent per service

definition: Copayment percentage per service


code: INSTANCE

display: specific

definition:
Description:A determiner that specifies that the Entity object represents a particular physical thing (as opposed to a universal, kind, or class of physical thing).

                           Discussion: It does not matter whether an INSTANCE still exists as a whole at the point in time (or process) when we mention it, for example, a drug product lot is an INSTANCE even though it has been portioned out for retail purpose.


code: GROUP

display: specific group

definition: A determiner that specifies that the Entity object represents a particular collection of physical things (as opposed to a universal, kind, or class of physical thing).  While the collection may resolve to having only a single individual (or even no individuals), the potential should exist for it to cover multiple individuals.


code: KIND

display: described

definition: Description:A determiner that specifies that the Entity object represents a universal, kind or class of physical thing (as opposed to a particular thing).


code: GROUPKIND

display: described group

definition: A determiner that specifies that the Entity object represents a universal, kind or class of collections physical things.  While the collection may resolve to having only a single individual (or even no individuals), the potential should exist for it to cover multiple individuals.


definition: The described quantified determiner indicates that the given Entity is taken as a general description of a specific amount of a thing. For example, QUANTIFIED_KIND of syringe (quantity = 3,) stands for exactly three syringes.

display: described quantified


display: Second intensive care unit

de: nicht verwendet

nl: Tweede intensive care unit


display: Second private room

nl: Tweede eigen kamer


display: Second semi-private room

nl: Tweede semi-eigen kamer


code: ICU

display: Intensive care unit

de: Intensivstation

nl: Intensive care unit


code: PRI

display: Private room

de: Einbettzimmer

nl: Eigen kamer


code: SPR

display: Semi-private room

de: Zweibettzimmer

nl: Semi-eigen kamer


display: Admission status is valid; used for grouping


display: Admission status is valid; not used for grouping


display: Admission status is invalid; not used for grouping


display: Admission status is invalid; default value used for grouping


code: AEXPOS

display: acquisition exposure

definition:
Description:

                        An acquisition exposure act describes the proximity (location and time) through which the participating entity was potentially exposed to a physical (including energy), chemical or biological agent from another entity.  The acquisition exposure act is used in conjunction with transmission exposure acts as part of an analysis technique for contact tracing.  Although an exposure can be decomposed into transmission and acquisition exposures, there is no requirement that all exposures be treated in this fashion.

                           Constraints:  The Acquisition Exposure inherits the participation constraints that apply to Exposure with the following exception.  The EXPSRC (exposure source) participation must never be associated with the Transmission Exposure either directly or via context conduction.

hierarchy: ACT EXPOS


code: DOCSECT

display: document section

definition: A context that subdivides the body of a document. Document sections are typically used for human navigation, to give a reader a clue as to the expected content. Document sections are used to organize and provide consistency to the contents of a document body. Document sections can contain document sections and can contain entries.

hierarchy: ACT _ActClassRecordOrganizer CONTAINER


definition: A public health case is an Observation representing a condition or event that has a specific significance for public health. Typically it involves an instance or instances of a reportable infectious disease or other condition. The public health case can include a health-related event concerning a single individual or it may refer to multiple health-related events that are occurrences of the same disease or condition of interest to public health. An outbreak involving multiple individuals may be considered as a type of public health case. A public health case definition (Act.moodCode = "definition") includes the description of the clinical, laboratory, and epidemiologic indicators associated with a disease or condition of interest to public health. There are case definitions for conditions that are reportable, as well as for those that are not. There are also case definitions for outbreaks. A public health case definition is a construct used by public health for the purpose of counting cases, and should not be used as clinical indications for treatment. Examples include AIDS, toxic-shock syndrome, and salmonellosis and their associated indicators that are used to define a case.

code: CASE

display: public health case

hierarchy: ACT OBS COND


code: POS

display: position

definition: An observation denoting the physical location of a person or thing based on a reference coordinate system.

hierarchy: ACT OBS


code: ROIOVL

display: overlay ROI

definition: A Region of Interest (ROI) specified for an image using an overlay shape. Typically used to make reference to specific regions in images, e.g., to specify the location of a radiologic finding in an image or to specify the site of a physical finding by "circling" a region in a schematic picture of a human body. The units of the coordinate values are in pixels.  The origin is in the upper left hand corner, with positive X values going to the right and positive Y values going down. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type "subject" (SUBJ), which must always be present.

hierarchy: ACT OBS _ActClassROI


code: POL

display: polypeptide

definition: Description:A polypeptide resulting from the translation of a gene.

hierarchy: ACT OBS GEN


code: ENTRY

display: entry

definition: This context represents the information acquired and recorded for an observation, a clinical statement such as a portion of the patient's history or an inference or assertion, or an action that might be intended or has actually been performed. This class may represent both the actual data describing the observation, inference, or action, and optionally the details supporting the clinical reasoning process such as a reference to an electronic guideline, decision support system, or other knowledge reference.


code: GEN

display: genomic observation

definition: Description:An observation of genomic phenomena.


code: INVE

display: invoice element

definition: Represents concepts related to invoice processing in health care


code: PROC

display: procedure

definition:
An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject.

                           Examples: : Procedures may involve the disruption of some body surface (e.g. an incision in a surgical procedure), but they also include conservative procedures such as reduction of a luxated join, chiropractic treatment, massage, balneotherapy, acupuncture, shiatsu, etc. Outside of clinical medicine, procedures may be such things as alteration of environments (e.g. straightening rivers, draining swamps, building dams) or the repair or change of machinery etc.


code: ROIBND

display: bounded ROI

definition: A Region of Interest (ROI) specified for a multidimensional observation, such as an Observation Series (OBSSER). The ROI is specified using a set of observation criteria, each delineating the boundary of the region in one of the dimensions in the multidimensional observation. The relationship between a ROI and its referenced Act is specified through an ActRelationship of type subject (SUBJ), which must always be present. Each of the boundary criteria observations is connected with the ROI using ActRelationships of type "has component" (COMP). In each boundary criterion, the Act.code names the dimension and the Observation.value specifies the range of values inside the region. Typically the bounded dimension is continuous, and so the Observation.value will be an interval (IVL) data type. The Observation.value need not be specified if the respective dimension is only named but not constrained. For example, an ROI for the QT interval of a certain beat in ECG Lead II would contain 2 boundary criteria, one naming the interval in time (constrained), and the other naming the interval in ECG Lead II (only named, but not constrained).


code: STORE

display: storage

definition: The act of putting something away for safe keeping. The "something" may be physical object such as a specimen, or information, such as observations regarding a specimen.


code: INFRM

display: inform

definition:
The act  of transmitting information and understanding about a topic to a subject where the participation association must be SBJ.

                           Discussion: This act may be used to request that a patient or provider be informed about an Act, or to indicate that a person was informed about a particular act.


code: EHR

display: electronic health record

definition:
A context that comprises all compositions. The EHR is an extract that includes the entire chart.

                           NOTE: In an exchange scenario, an EHR is a specialization of an extract.

hierarchy: ACT _ActClassRecordOrganizer EXTRACT


code: REV

display: review

definition: The act of examining and evaluating the subject, usually another act. For example, "This prescription needs to be reviewed in 2 months."


code: SUBST

display: Substitution

definition:
Definition: Indicates that the subject Act has undergone or should undergo substitution of a type indicated by Act.code.

                        Rationale: Used to specify "allowed" substitution when creating orders, "actual" susbstitution when sending events, as well as the reason for the substitution and who was responsible for it.


code: ACTN

display: action

definition: Sender asks addressee to do something depending on the focal Act of the payload.  An example is "fulfill this order".  Addressee has responsibilities to either reject the message or to act on it in an appropriate way (specified by the specific receiver responsibilities for the interaction).

hierarchy: ACT CACT


definition:
Lying on the back, on an inclined plane, typically about 30-45 degrees with head raised and feet lowered.

                              Deprecation Comment:
                           This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation.  The same code has been added to the ObservationValue code system.

code: RTRD

display: reverse trendelenburg


code: BATTERY

display: battery

definition:
Definition: An observation that is composed of a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are run together because of automation. A battery can define required and optional component observations and, in some cases, will define complex rules that determine whether or not a particular observation is made. BATTERY is a constraint on the Observation class in that it is understood to always be composed of component observations.

                           UsageNotes: The focus in a BATTERY is that it is composed of individual observations. In request (RQO) mood, a battery is a request to perform the component observations. In event (EVN) mood a battery is a reporting of associated set of observation events. In definition mood a battery is the definition of the associated set of observations.

                           Examples: Vital signs, Full blood count, Chemistry panel.


code: LIST

display: working list

definition: Working list collects a dynamic list of individual instances of Act via ActRelationship which reflects the need of an individual worker, team of workers, or an organization to manage lists of acts for many different clinical and administrative reasons. Examples of working lists include problem lists, goal lists, allergy lists, and to-do lists.


code: EXPOS

display: exposure

definition:
An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity.

                           Examples:  The following examples are provided to indicate what interactions are considered exposures rather than other types of Acts:

                              A patient accidentally receives three times the recommended dose of their medication due to a dosing error.

                                    This is a substance administration.  Public health and/or safety authorities may also be interested in documenting this with an associated exposure.

                              A patient accidentally is dispensed an incorrect medicine (e.g., clomiphene instead of clomipramine).  They have taken several doses before the mistake is detected.  They are therefore "exposed" to a medicine that there was no therapeutic indication for them to receive.

                                    There are several substance administrations in this example.  Public health and/or safety authorities may also be interested in documenting this with associated exposures.

                              In a busy medical ward, a patient is receiving chemotherapy for a lymphoma.  Unfortunately, the IV infusion bag containing the medicine splits, spraying cytotoxic medication over the patient being treated and the patient in the adjacent bed.

                                    There are three substance administrations in this example.  The first is the intended one (IV infusion) with its associated (implicit) exposure.  There is an incident with an associated substance administration to the same patient involving the medication sprayed over the patient as well as an associated exposure.  Additionally, the incident includes a substance administration involving the spraying of medication on the adjacent patient, also with an associated exposure.

                              A patient who is a refugee from a war-torn African nation arrives in a busy inner city A&E department suffering from a cough with bloody sputum.  Not understanding the registration and triage process, they sit in the waiting room for several hours before it is noticed that they have not booked in.  As soon as they are being processed, it is suspected that they are suffering from TB.  Vulnerable (immunosuppressed) patients who were sharing the waiting room with this patient may have been exposed to the tubercule bacillus, and must be traced for investigation.

                                    This is an exposure (or possibly multiple exposures) in the waiting room involving the refugee and everyone else in the waiting room during the period.  There might also be a number of known or presumed substance administrations (coughing) via several possible routes.  The substance administrations are only hypotheses until confirmed by further testing.

                              A patient who has received an elective total hip replacement procedure suffers a prolonged stay in hospital, due to contracting an MRSA infection in the surgical wound site after the surgery.

                                    This is an exposure to MRSA.  Although there was some sort of substance administration, it's possible the exact mechanism for introduction of the MRSA into the wound will not be identified.

                              Routine maintenance of the X-ray machines at a local hospital reveals a serious breach of the shielding on one of the machines.  Patients who have undergone investigations using that machine in the last month are likely to have been exposed to significantly higher doses of X-rays than was intended, and must be tracked for possible adverse effects.

                                    There has been an exposure of each patient who used the machine in the past 30 days. Some patients may have had substance administrations.

                              A new member of staff is employed in the laundry processing room of a small cottage hospital, and a misreading of the instructions for adding detergents results in fifty times the usual concentration of cleaning materials being added to a batch of hospital bedding.  As a result, several patients have been exposed to very high levels of detergents still present in the "clean" bedding, and have experienced dermatological reactions to this.

                                    There has been an incident with multiple exposures to several patients.  Although there are substance administrations involving the application of the detergent to the skin of the patients, it is expected that the substance administrations would not be directly documented.

                              Seven patients who are residents in a health care facility for the elderly mentally ill have developed respiratory problems. After several months of various tests having been performed and various medications prescribed to these patients, the problem is traced to their being "sensitive" to a new fungicide used in the wall plaster of the ward where these patients reside.

                                    The patients have been continuously exposed to the fungicide.  Although there have been continuous substance administrations (via breathing) this would not normally be documented as a substance administration.

                              A patient with osteoarthritis of the knees is treated symptomatically using analgesia, paracetamol (acetaminophen) 1g up to four times a day for pain relief.  His GP does not realize that the patient has, 20 years previously (while at college) had severe alcohol addiction problems, and now, although this is completely under control, his liver has suffered significantly, leaving him more sensitive to hepatic toxicity from paracetamol use.  Later that year, the patient returns with a noticeable level of jaundice.  Paracetamol is immediately withdrawn and alternative solutions for the knee pain are sought.  The jaundice gradually subsides with conservative management, but referral to the gastroenterologist is required for advice and monitoring.

                                    There is a substance administration with an associated exposure.  The exposure component is based on the relative toxic level of the substance to a patient with a compromised liver function.

                              A patient goes to their GP complaining of abdominal pain, having been discharged from the local hospital ten days' previously after an emergency appendectomy.  The GP can find nothing particularly amiss, and presumes it is post operative surgical pain that will resolve.  The patient returns a fortnight later, when the GP prescribes further analgesia, but does decide to request an outpatient surgical follow-up appointment.  At this post-surgical outpatient review, the registrar decides to order an ultrasound, which, when performed three weeks later, shows a small faint inexplicable mass.  A laparoscopy is then performed, as a day case procedure, and a piece of a surgical swab is removed from the patient's abdominal cavity.  Thankfully, a full recovery then takes place.

                                    This is a procedural sequelae.  There may be an Incident recorded for this also.

                              A patient is slightly late for a regular pacemaker battery check in the Cardiology department of the local hospital.  They are hurrying down the second floor corridor.  A sudden summer squall has recently passed over the area, and rain has come in through an open corridor window leaving a small puddle on the corridor floor.  In their haste, the patient slips in the puddle and falls so badly that they have to be taken to the A&E department, where it is discovered on investigation they have slightly torn the cruciate ligament in their left knee.

                                    This is not an exposure.  There has been an incident.

                           Usage Notes: This class deals only with opportunity and not the outcome of the exposure; i.e. not all exposed parties will necessarily experience actual harm or benefit.

                        Exposure differs from Substance Administration by the absence of the participation of a performer in the act.

                        The following participations SHOULD be used with the following participations to distinguish the specific entities:

                              The exposed entity participates via the "exposure target" (EXPTRGT) participation.

                              An entity that has carried the agent transmitted in the exposure participates via the "exposure source" (EXSRC) participation.  For example:

                                    a person or animal who carried an infectious disease and interacts (EXSRC) with another person or animal (EXPTRGT) transmitting the disease agent;

                                    a place or other environment (EXSRC) and a person or animal (EXPTRGT) who is exposed in the presence of this environment.

                              When it is unknown whether a participating entity is the source of the agent (EXSRC) or the target of the transmission (EXPTRGT), the "exposure participant" (EXPART) is used.

                              The physical (including energy), chemical or biological substance which is participating in the exposure uses the "exposure agent" (EXPAGNT) participation.  There are at least three scenarios:

                                    the player of the Role that participates as EXPAGNT is the chemical or biological substance mixed or carried by the scoper-entity of the Role (e.g., ingredient role); or

                                    the player of the Role that participates as EXPAGNT is a mixture known to contain the chemical, radiological or biological substance of interest; or

                                    the player of the Role that participates as a EXPAGNT is known to carry the agent (i.e., the player is a fomite, vector, etc.).

                        The Exposure.statusCode attribute should be interpreted as the state of the Exposure business object (e.g., active, aborted, completed) and not the clinical status of the exposure (e.g., probable, confirmed).  The clinical status of the exposure should be associated with the exposure via a subject observation.

                           Design Comment: The usage notes require a clear criterion for determining whether an act is an exposure or substance administration-deleterious potential, uncertainty of actual transmission, or otherwise. SBADM states that the criterion is the presence of a performer-but there are examples above that call this criterion into question (e.g., the first one, concerning a dosing error).


code: POSACC

display: position accuracy

definition: Description:An observation representing the degree to which the assignment of the spatial coordinates, based on a matching algorithm by a geocoding engine against a reference spatial database, matches true or accepted values.

hierarchy: ACT OBS POS


code: SEQVAR

display: bio sequence variation

definition: Description:A variation in a sequence as described by BioSequence.


code: STC

display: state transition control

definition: Description: Sender transmits a status change pertaining to the focal act of the payload. This status of the focal act is the final state of the state transition. This can be either a request or an event, according to the mood of the control act.


code: DOC

display: document

definition:
The notion of a document comes particularly from the paper world, where it corresponds to the contents recorded on discrete pieces of paper. In the electronic world, a document is a kind of composition that bears resemblance to their paper world counter-parts. Documents typically are meant to be human-readable.

                        HL7's notion of document differs from that described in the W3C XML Recommendation, in which a document refers specifically to the contents that fall between the root element's start-tag and end-tag. Not all XML documents are HL7 documents.


code: ACSN

display: accession

definition: A unit of work, a grouper of work items as defined by the system performing that work. Typically some laboratory order fulfillers communicate references to accessions in their communications regarding laboratory orders. Often one or more specimens are related to an accession such that in some environments the accession number is taken as an identifier for a specimen (group).