Project:
|
Reported Clinical Information
Clinical information about a patient, such as immunizations, procedures and other interventions, etc., reported by a patient or by another non-practitioner, e.g., a caregiver.<br/>This entity contains only the attributes and relationships common to all types of reported clinical information (e.g. to immunizations, procedures, etc.). <br/><br/>Since reported information is provided by a non-practitioner, expectations about its accuracy are low. Thus, although the information may sometimes be accurate (e.g., when a patient has access to prescriptions or to the report of a vaccination performed in a clinic), it may also be incomplete and inaccurate, as some patients may not recall their medical history precisely. <br/>
- Attributes
- Associations To
- Associations From
- Constraints
- Other Links
| Attribute |
Type |
|
Reported Clinical Information Type Code
|
Codeable Concept
|
|
Notes:
|
A coded concept that specifies the type/context of a Reported Clinical Information record (e.g., immunization, procedure). <br/><b><br/></b><b>Value set</b>:<br/><a href="../EA4/EA403.htm"><font color="#0000ff"><u>Supporting - Reported Clinical Information Type.xlsx</u></font></a> <br/><br/>
|
|
|
Reported Clinical Information Date Time
|
Date Time
|
|
Notes:
|
The reported date and, if known, the time of the clinical occurrence (e.g., immunization, procedure, other intervention). <br/><br/>If a specific date and/or time is not available, nor a reported patient's age (number or range), then free text can be entered in the Reported Clinical Information Date Time Age Description attribute.<br/><br/>Not to be confused with the date-time of reporting: this is the reported date-time of occurrence. <br/>
|
|
|
Reported Clinical Information Patient Age Number
|
Integer
|
|
Notes:
|
The reported age of the patient at the time of the clinical occurrence (e.g., immunization, procedure, other intervention).<br/><br/>If a minimum and/or maximum age at the time of occurrence is reported rather than a specific age (e.g., between 20 and 25 years, at least 30 years old), it should be entered in the Reported Clinical Information Patient Age Range attribute.<br/>
|
|
|
Reported Clinical Information Patient Age Unit of Measure Code
|
Codeable Concept
|
|
Notes:
|
A coded concept that specifies the unit of measure (e.g., years, months) of the reported age (number, not range) of the patient at the time of the clinical occurrence (e.g., immunization, procedure, other intervention).<br/><br/><b>Value set:</b><br/><a href="https://tgateway.infoway-inforoute.ca/vs/x_timeunitsofmeasure"><font color="#0000ff"><u>https://tgateway.infoway-inforoute.ca/vs/x_timeunitsofmeasure</u></font></a><a href="https://fhir.infoway-inforoute.ca/ValueSet/x_basicunitsofmeasure"><font color="#0000ff"><u> </u></font></a><br/>
|
|
|
Reported Clinical Information Patient Age Range
|
Range
|
|
Notes:
|
The reported minimum and/or maximum age of the patient at the time of the clinical occurrence (e.g. immunization, procedure, other intervention).<br/><br/>If a specific age is reported (e.g. 40 years old), it should be entered in the Reported Clinical Information Patient Age Range attribute.<br/><br/>Unit of Measure Code:<br/><br/><b>Value set:</b><br/><a href="https://tgateway.infoway-inforoute.ca/vs/x_timeunitsofmeasure"><font color="#0000ff"><u>https://tgateway.infoway-inforoute.ca/vs/x_timeunitsofmeasure</u></font></a> <br/>Constraints: <br/>for lower bound and upper bound of range, must have: <br/>low(Unit of Measure Code) = high(Unit of Measure Code)<br/>low(Value) and high(Value) both integers (decimal part = 0)<br/><br/><br/>
|
|
|
Reported Clinical Information Date Time Age Description
|
String
|
|
Notes:
|
Free text description of the reported date-time or patient's age at the time of the clinical occurrence (e.g., immunization, procedure, other intervention). <br/><br/>Can be used when exact values are not known or to provide additional information, which should be consistent with the entered values, if any. <br/>
|
|
|
Reported Clinical Information Performer Description
|
String
|
|
Notes:
|
Free text description (full or partial name as remembered, a phrase such as "the most senior doctor in the hospital", etc.) of the practitioner who performed the reported clinical service (e.g., immunization, procedure, other intervention).<br/><br/>Relevant for some types of clinical information, but not for others (e.g., does not apply to information reported in a medication statement). <br/><br/><br/>
|
|
|
Reported Clinical Information Prescriber Description
|
String
|
|
Notes:
|
Free text description (full or partial name as remembered, a phrase such as "the pharmacist who worked at that drugstore 5 years ago") of the practitioner who prescribed the reported medication or service (e.g. immunization). <br/><br/>Relevant for some types of clinical information, but not for others (e.g., does not apply to allergies and intolerances). <br/><br/>
|
|
|
Reported Clinical Information Location Description
|
String
|
|
Notes:
|
Free text description (site or place name as remembered, a phrase such as "in a mobile vaccination bus", etc.) of the location where the clinical service is reported to have occurred (e.g., immunization, procedure, other intervention). <br/><br/>If an actual structured location is entered (related Location entity instance), this description should be consistent with it (e.g., may not specify a site name incompatible with the entered structured location). <br/><br/>Relevant for some types of clinical information, but not for others (e.g., does not apply to information reported in a medication statement). <br/><br/>
|
|
|
Reported Clinical Information Source Code
|
Codeable Concept
|
|
Notes:
|
A coded concept that specifies the role type of the person who reported the information (e.g., patient, caregiver, family member). <br/><br/><b>Value set</b>: to be developed.<br/>
|
|
| Constraint |
| XOR: Reported Clinical Information Patient Age Number, Reported Clinical Information Patient Age Range (if both specified) |
|
