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HITSP/C154: HITSP Data Dictionary Component


1. Introduction

1.1 Overview

This specification is a library of the HITSP defined data elements that are used for mapping to data elements from the HITSP selected standards. It defines data elements that have been constrained or used in other HITSP documents (such as Components, Transactions, Transaction Packages) and facilitates the consistent use of these data elements across the various HITSP selected standards. It does not attempt to specify all the data elements for the standards selected by HITSP (i.e. only those constrained). The Data Elements are organized into modules to simplify navigation, such as Medications, Advance Directives, Immunizations, etc.

This specification does not enable the use of the data elements; this is accomplished by a HITSP construct that is based upon a specific standard (such as HL7, X12N, NCPDP, etc.). In order to facilitate harmonization of value sets across the various selected standards, this specification may define value set constraints. When this does not occur, it is because the data element does not require a value set or a harmonized value set was not determined. These value sets in turn reference standard terminologies in HITSP/C80 Clinical Document Message Terminology. HITSP/C154 does not define any other constraints (such as optionality) as those constraints are identified in the HITSP construct that enables the data element.

There are many ways that various HITSP documents may constrain a data element, some examples include:

  • Specifying the Optionality of a data element, such as required, required if known or conditional
  • Selecting value sets for the data element (which may be the same as HITSP/C154 or additional constraints)
  • Refining the information that may be provided in that data element when it is used in an exchange


HITSP/TN903 Data Architecture provides a more detailed explanation about the use of data elements (and other data architecture concepts) within HITSP.

1.2 Copyright Permissions

© This material may be copied without permission from ANSI only if and to the extent that the text is not altered in any fashion and ANSI's copyright is clearly noted.

Certain materials contained in this Component are reproduced from HL7 Implementation Guide: CDA Release 2 - Continuity of Care Document (CCD) with permission of Health Level Seven, Inc. No part of the material may be copied or reproduced in any form outside of the Interoperability Specification documents, including an electronic retrieval system, or made available on the Internet without the prior written permission of Health Level Seven, Inc. Copies of standards included in this Component may be purchased from the Health Level Seven, Inc. Material drawn from these standards is credited where used.

1.3 Reference Documents

A list of key reference documents and background material is provided in the table below. HITSP-maintained reference documents can be retrieved from the HITSP Web Site

Reference Document Document Description
HITSP Acronyms List Exit Disclaimer [publicaa.ansi.org] Lists and defines the acronyms used in this document
HITSP Glossary Exit Disclaimer [publicaa.ansi.org] Provides definitions for relevant terms used by HITSP documents
TN901 - Clinical Documents TN901 is a reference document that provides the overall context for use of the HITSP Care Management and Health Records constructs
TN903 - Data Architecture TN903 is a reference document that provides the overall context for use of the HITSP Data Architecture constructs
TN904 - Harmonization Framework and Exchange Architecture TN904 is a reference document that provides the overall context for use of the HITSP Harmonization Framework and Exchange Architecture

1.4 Conformance

This section describes the conformance criteria, which are objective statements of requirements that can be used to determine if a specific behavior, function, interface, or code set has been implemented correctly.

1.4.1 Conformance Criteria

In order to claim conformance to this construct specification, an implementation must satisfy all the requirements and mandatory statements listed in this specification, the associated HITSP Interoperability Specification or Capability, its associated construct specifications, as well as conformance criteria from the selected base and composite standards. A conformant system must also implement all of the required interfaces within the scope, subset or implementation option that is selected from the associated Interoperability Specification.

Claims of conformance may only be made for the overall HITSP Interoperability Specification or Capability with which this construct is associated.

1.4.2 Conformance Scoping, Subsetting, and Options

A HITSP Interoperability Specification or Capability must be implemented in its entirety for an implementation to claim conformance to the specification. HITSP may define the permissibility for interface scoping, subsetting or implementation options by which the specification may be implemented in a limited manner. Such scoping, subsetting and options may extend to associated constructs, such as this construct. This construct must implement all requirements within the selected scope, subset or options as defined in the associated Interoperability Specification or Capability to claim conformance.

1.5 Document Conventions

1.5.1 Key Words

The key words SHALL, SHALL NOT, SHOULD, SHOULD NOT and MAY are to be interpreted as described in RFC 2119 and will appear when used in that fashion in this TYPEFACE.

The key words REQUIRED and OPTIONAL are also to be interpreted as described in RFC 2119 when they are used to indicate the optionality of components used in an exchange.

1.5.2 Constraints

Constraints in this document will appear as shown below.

C83-[DE-7.04-1] The problem type SHALL be coded as specified in HITSP/C80 section 2.2.1.1.4.1.2 Problem Type. The first portion identifies the type of artifact being constrained. The second portion is the identifier for that artifact, and the final portion is the sequence number of the constraint on that artifact within this document. Constraints specific to CDA usage will contain the string CDA before the final number

2.1 Context Overview

This section provides an introduction to the concepts used in describing the data elements used in HITSP specifications. The HITSP Data Elements in this document are organized into modules described in Table 2-1 below. The module identifier number is given in the first column, followed by the name and definition of what appears in that module. These modules are described in more detail below in Section 2.1.2 HITSP Data Elements.

Table 2-1 Module Categories

Number Module name Definition
1 Person Information This includes name, address, contact information, personal identification information, ethnic and racial affiliation and marital status of a person
2 Language This includes the language spoken by subject
3 Support This includes the patient's sources of support, such as immediate family, relatives and/or guardians. This includes next of kin, caregivers, support organizations, and key contacts relative to healthcare decisions. Support providers may include providers of healthcare related services, such as a personally controlled health record, or registry of emergency contacts
4 Healthcare Providers This includes a list of the healthcare providers and organizations that provide or have provided care to the patient
5 Insurance Providers and Players This includes data about the organizations or individuals who may pay for a patient's healthcare, and the relationships, demographics and identifiers of those individuals with respect to the payer. Such organizations or individuals may be health insurance plans, other payers, guarantors, parties with financial responsibility, some combination of payers or the patient directly
6 Allergies and Drug Sensitivities This includes the allergy or intolerance conditions, severity and associated adverse reactions suffered by the patient
7 Conditions This includes relevant clinical problems and conditions for which the patient is receiving care, including information about onset, severity, and providers treating the condition. Conditions are broader than, but include diagnoses
8 Medications This includes the patient's prescription or non-prescription medications and medication history, and may include prescriptions, fulfillments and medication administration activities
9 Pregnancy This includes information about the patient's current and past pregnancy status
10 Information Source This includes information about the author or creator of the information contained within the exchange
12 Advanced Directive This includes data defining the patient.s advance directives and supporting documentation. It can include information about the existence of living wills, healthcare proxies, and CPR and resuscitation status
13 Immunizations This includes data describing the patient's immunization history
14 Vital Signs This includes data about the patient's vital signs
15 Test Results This includes data about current and historical test results from laboratory or other diagnostic testing performed on the patient
16 Encounter This includes data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and email
17 Procedures This includes data describing procedures performed on a patient
18 Family History This includes data defining the patient's genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient's health
19 Social History This includes data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history that have a potential impact on the patient's health
20 Medical Equipment This includes implanted and external medical devices and equipment that a patient's health status depends on, as well as any pertinent equipment or device history
21 Functional Status This includes data defining the patient.s functional status with respect to, Ambulatory ability, Mental status or competency, Activities of Daily Living, including bathing, dressing, feeding, grooming, Home/living situation having an effect on the health status of the patient, Ability to care for self
22 Plan of Care This includes data defining prospective or intended orders, interventions, encounters, services, and procedures for the patient
23 Clinical Research This includes data elements and common identifier variables that pertain to research-specific workflow
24 Order This includes data describing orders for a patient
25 Specimen This includes data describing the specimen information associated with an order and the results

The HITSP Data Dictionary defines the library of Data Elements that may be used by HITSP constructs in standards based exchanges. The Data Elements are organized into modules to simplify navigation, such as Medications, Advance Directives, Immunizations, etc.


2.1.2.1 Personal Information

The personal information module contains the name, address, contact information, personal identification information, ethnic and racial affiliation and marital status of the person. See the HL7 Continuity of Care Document Section 2.5 for constraints applicable to this module.

2.1.2.2 Language Spoken

This module indicates the language spoken by the subject.

2.1.2.3 Support

This module contains the patient's sources of support, such as immediate family, relatives and guardians. Support information also includes next of kin, caregivers and support organizations. Support providers may include providers of healthcare related services, such as a personally controlled health record, or registry of emergency contacts.

2.1.2.4 Healthcare Provider

This module contains the healthcare providers involved in the current or pertinent historical care of the patient.

2.1.2.5 Insurance Provider

This insurance provider module contains data about the entities or other individuals who may pay for a patient's healthcare. Such entities or individuals may be health insurance plans, other payers, and guarantors, parties with financial responsibility, some combination of payers or the patient directly. This module is used to define which entity or combination of entities has any financial responsibility for a patient's care.

2.1.2.6 Allergy/Drug Sensitivity

This module contains the allergy or intolerance conditions and the associated adverse reactions suffered by the patient.

2.1.2.7 Condition

This module contains relevant clinical problems. See the HL7 Continuity of Care Document Section 3.5 for constraints applicable to this module.

2.1.2.8 Medication

This module contains a patient's prescription or non-prescription medications and pertinent medication history. See the HL7 Continuity of Care Document Section 3.9 for constraints applicable to this module.

2.1.2.9 Pregnancy

This module contains information about the patient's current and historical pregnancy status.

2.1.2.10 Information Source

This module describes information about the original author of the exchange and reference to source materials that can be provided in an exchange.

2.1.2.11 General Purpose Data Elements

This collection of data elements applies to a variety of exchanges.

2.1.2.12 Advance Directive

This module contains data describing the patient's Advance Directive and any reference to supporting documentation. This section contains data such as the existence of living wills, healthcare proxies and CPR and resuscitation status. The custodian of these documents may be described.

2.1.2.13 Immunization

This module contains data describing the patient's immunization history.

2.1.2.14 Vital Sign

This module contains current and relevant historical vital signs for the patient. Vital Signs are a subset of Results (see Section 2.1.2.15), but are reported in this section to follow clinical conventions. The differentiation between Vital Signs and Results varies by clinical context. Common examples of vital signs include temperature, height, weight, blood pressure, etc. However, some clinical contexts may alter these common vital signs, for example in neonatology "height" may be replaced by "crown-to-rump" measurement.

2.1.2.15 Result

This module contains current and relevant historical result observations for the patient. The scope of "observations" is broad with the exception of "vital signs" which are contained in the Vital Signs sections (see Section 2.1.2.14 above).

2.1.2.16 Encounter

This module contains data describing the interactions between the patient and clinicians. Interaction includes both in-person and non-in-person encounters such as telephone and email communication.

2.1.2.17 Procedure

This module contains a coded entry indicating a procedure performed on a patient.

2.1.2.18 Family History

This module contains data defining the patient's genetic risk factors.

2.1.2.19 Social History

The text adapted from HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.7 Social History, begins here:

This module contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.

The text adapted from HL7 CDA Release 2 - Continuity of Care Document (CCD), Section 3.7 Social History, ends here.

Table 2-39 Social History Data Mapping Table - Definitions: Social History Event Entry

2.1.2.20 Medical Equipment

Medical Equipment includes implanted and external medical devices and equipment that a patient's health status depends on, as well as any pertinent equipment or device history.

2.1.2.21 Functional Status

The functional status module contains data defining the patient's functional status with respect to Ambulatory ability, Mental status or competency, Activities of Daily Living, including bathing, dressing, feeding, grooming, Home/living situation having an effect on the health status of the patient or their Ability to care for themselves.

2.1.2.22 Plan of Care

The plan of care contains data defining prospective or intended orders, interventions, encounters, services, and procedures for the patient.

2.1.2.23 Clinical Research

The clinical research module contains data defining data elements and common identifier variables that pertain to research-specific workflow.

2.1.2.24 Order

This module contains data defining the patient's order.

2.1.2.25 Specimen

This module contains data defining the Specimen related to an Order.

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SortData Elements
Identifier Sort
Definition Sort
Constraints Sort
Timestamp 1.01 The date and time that this exchange has been created
Person ID 1.02 An identifier that uniquely identifies the individual to which the exchange refers and connects that document to the individual's personal health record. Potential security risks associated with use of SSN or driver's license for this element suggest that these should not be used routinely
Person Address 1.03 The current address of the individual to which the exchange refers. Multiple addresses are allowed and the work address may be a method of disclosing the employer C154-[DE-1.03-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State C154-[DE-1.03-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code C154-[DE-1.03-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
Person Phone/Email/URL 1.04 A telephone number (voice or fax), e-mail address or other locator for a resource mediated by telecommunication equipment. HITSP specifies just this one data element to describe phone numbers, pagers, e-mail addresses and URLs, but these may appear in different data elements in the selected standards. The patient may designate one or more of these contact numbers as the preferred method of contact and temporary items can be entered for use on specific effective dates
Person Name 1.05 The individual to whom the exchange refers. Multiple names are allowed to retain birth name, maiden name, legal names and aliases as required
Gender 1.06 Gender is used to refer to administrative sex rather than biological sex and therefore should easily be classified into female and male. It is included in the exchange for purposes of linking to insurance information and other patient identification linkages and the value chosen by the patient should reflect the information under which any insurance or financial information will be filed, as well as the same information given to other healthcare providers, institutions or health data exchange networks C154-[DE-1.06-1] Gender SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.1. Administrative Gender
Person Date of Birth 1.07 The date and time of birth of the individual to which this Exchange refers. The date of birth is typically a key patient identifier variable and used to enable computation of age at the effective date of any other data element. It is assumed to be unique and fixed throughout the patient's lifetime
Marital Status 1.08 A value representing the domestic partnership status of a person. Marital status is important in determining insurance eligibility and other legal arrangements surrounding care. Marital status often changes during a patient's lifetime so the data should relate to the effective date of the patient data object and not be entered with multiple values like an address or contact number. This element should only have one instance reflecting the current status of the individual at the time the Exchange is produced. Former values might be part of the personal and social history C154-[DE-1.08-1] Marital Status SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.3.2 Marital Status CDA and HLV3
Religious Affiliation 1.09 Religious affiliation is the religious preference of the person C154-[DE-1.09--1] Religious affiliation SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.8 Religious Affiliation
Race 1.10 Race is usually a single valued term that may be constant over that patient's lifetime. The coding of race is aligned with public health and other federal reporting standards of the CDC and the Census Bureau. Typically the patient is the source of the content of this element. However, the individual may opt to omit race. In this event, some healthcare organizations that receive the Summary Document may choose to enter an observed race as their current practice for manual registration. Such organization observed race data should be differentiated from patient sourced data in the patient's registration summary C154-[DE-1.10-1] Race SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.7 Race
Ethnicity 1.11 Ethnicity is a term that extends the concept of race. The coding of ethnicity is aligned with public health and other federal reporting standards of the CDC and the Census Bureau C154-[DE-1.11-1] Ethnicity SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.2 Ethnicity
Mother's Maiden Name 1.12 The family name under which the Mother was born
Multiple Birth Indicator 1.13 Indicates whether a patient was part of a multiple birth
Birth Order 1.14 The value (number) indicating the patient's birth order when the patient was part of a multiple birth
Age 1.15 The Person's age. This is normally a value derived, but in some cases this may be the only information provided (no birth date) C154-[DE-1.15-1] ] The Age SHALL use UCUM Age Units
Birth Place 1.16 The location of the patient's birth C154-[DE-1.16-1] If born in the United States, the state part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State C154-[DE-1.16-2] If born in the United States the postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code C154-[DE-1.16-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
Identity Unknown Indicator 1.17 Indicates whether or not the patient's/person's identity is known
Patient Account Number 1.18 The patient account number assigned by accounting to which all charges, payments, etc., are recorded
Author Time 10.01 The time at which this information was created
Author Name 10.02 The name of the person who created the information content
Reference 10.03 A reference to the original document from which this information was obtained
Reference Document ID 10.04 Identifier of the external document that was referenced
Reference Document URL 10.05 A URL from which this document may be retrieved Note: Depending on the architectural variant applied, only references to documents which have been registered, so as to ensure that the registry/repository/system access control mechanisms are used to access these documents
Information Source Name 10.06 The name of the person or organization that provided the information
Free Text Comment 11.01 A free text comment that cannot be represented using existing data elements
Reason 11.02 The reason given for a specific intervention or the reason it did not occur
Tense 11.03 Tense is a modifier to a data element used to express time as it relates to a data element. For example, an event has occurred in the past or will occur in the future
Advance Directive Type 12.01 This is a coded value describing the type of the Advance Directive C154-[DE-12.02-1] The advance directive SHALL be coded as specified in HITSP/C80 Section 2.2.3.10.1 Advance Directive Type
Advance Directive Free Text Type 12.02 Free text comment to describe the Advance Directive Type
Effective Date 12.03 The effective date for the Advance Directive
Custodian of the Document 12.04 Name, address or other contact information for the person or organization that can provide a copy of the document
Refusal 13.01 A flag that the immunization event did not occur. The nature of the refusal (e.g., patient or patient caregiver refused, adverse reaction)
Administered Date 13.02 The date and time of substance was administered or refused, i.e., when the immunization was administered to the patient, or refused by the patient or patient caregiver
Medication Series Number 13.03 Indicate which in a series of administrations a particular administration represents (e.g. "Hepatitis B vaccine number 2")
Reaction 13.04 Any noted intended or unintended effects of the product. For example: full body rash, nausea, rash resolved
Performer 13.05 The person that administered the immunization to the patient (may include both a name and an identifier)
Coded Product Name 13.06 A code describing the product from a controlled vocabulary C154-[DE-13.06-1] Immunizations SHALL be coded as specified in HITSP/C80 Section 2.2.3.5.1 Vaccines Administered.
Free Text Product Name 13.07 The name of the substance or product without reference to a specific vendor (e.g., generic or other non-proprietary name). If a Coded Product Name is present, this is the text associated with the coded concept C154-[DE-13.07-1] This SHOULD be sufficient for a provider to identify a medication, and MAY include additional information such as strength, dose form, etc. If the name of the product is unknown, the type, purpose or other description MAY be supplied
Drug Manufacturer 13.08 The manufacturer of the substance or product as ordered or supplied. The distributor may be supplied if the manufacturer is not known
Lot Number 13.09 The manufacturer's production lot number for the administered product
Refusal Reason 13.10 When an immunization is refused, this provides a coded representation of the reason for refusing the immunization C154-[DE-13.10-1] The reason for refusal SHALL be coded as specified in HITSP/C80 Section 2.2.3.5.3 No Immunization Reason
Immunization Information Source 13.11 The immunization information source is a value which indicates where the information about a specific immunization record came from C154--[DE-13.11-1] The Administration notes SHALL be coded using the HITSP/C80 Section 2.2.3.5.4 Immunization Information Source
Vital Sign Result ID 14.01 An identifier for this specific vital sign observation
Vital Sign Result Date/Time 14.02 The biologically relevant date/time for the vital sign observation
Vital Sign Result Type 14.03 A coded representation of the vital sign observation performed C154-[DE-14.03-1] Vital signs SHOULD be coded as specified in HITSP/C80 Section 2.2.3.6.4 Vital Sign Result Type
Vital Sign Result Status 14.04 Status for this vital sign observation, e.g., complete, preliminary
Vital Sign Result Value 14.05 The value of the result, including units of measure if applicable
Vital Sign Result Interpretation 14.06 An abbreviated interpretation of the vital sign observation, e.g., normal, abnormal, high, etc
Vital Sign Result Reference Range 14.07 Reference range(s) for the vital sign observation
Result ID 15.01 An identifier for this specific observation
Result Date/Time 15.02 The biologically relevant date/time for the observation
Result Type 15.03 A coded representation of the observation performed C154-[DE-15.03-1] Result Type SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96) C154-[DE-15.03-2] Result Type for laboratory results SHOULD be coded as specified in HITSP/C80 Section 2.2.3.6.1 Laboratory Observations
Result Status 15.04 Status for this observation, e.g., complete, preliminary
Result Value 15.05 The value of the result, including units of measure if applicable
Result Interpretation 15.06 An abbreviated interpretation of the observation, e.g., normal, abnormal, high, etc C154-[DE-15.02-1] Result Interpretation SHALL be coded as specified in HITSP/C80 Section 2.2.3.6.3 Result Normalcy Status
Result Reference Range 15.07 Reference range(s) for the observation
Encounter ID 16.01 An identifier for this Encounter
Encounter Type 16.02 This is a coded value describing the type of the Encounter C154-[DE-16.02-1] Encounter Type SHOULD be coded as specified in HITSP/C80 Section 2.2.3.9.3 Encounter Type
Encounter Free Text Type 16.03 Free text describing the Encounter Type
Encounter Date/Time 16.04 The date and time of the Encounter, including duration if pertinent
Encounter Provider 16.05 Name and other information for the person or organization performed or hosted the Encounter
Admission Source 16.06 Identifies where the patient was admitted C154-[DE-16.06-1] The Admission Source SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.1 Admission Source
Admission Type 16.07 Indicates the circumstances under which the patient was or will be admitted C154-[DE-16.07-1] The Admission Type SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.2 Admission Type
Immunization Services Funding Eligibility 16.08 Immunization Services Funding Eligibility is a point in time marker for eligibility category that describes a person. The categories are specified by the federal Vaccines for Children program. It does not refer to who actually paid for a given immunization
Discharge Disposition 16.09 Discharge Disposition (sometimes called "Discharge Status") is the person's anticipated location or status following the encounter (e.g. death, transfer to home/hospice/SNF/AMA) - uses standard claims-based codes C154-[DE-16.09-1] The Discharge Disposition SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.4 Discharge Disposition
Patient Class 16.10 This is used to categorize patients by the site where the encounter occurred , e.g., Emergency, Inpatient, or Outpatient C154-[DE-16.10-1] Patient Class SHALL be coded as specified in HITSP/C80 Section 2.2.3.9.5 Patient Class
In Facility Location 16.11 The service delivery location
Arrival Date/Time 16.12 The date and time the patient arrived at the location
Reason for Visit 16.13 Indicates the rationale for the encounter
Order to Admit Date/Time 16.14 The date and time the provider has ordered that the patient be admitted
Decision to Admit Date/Time 16.15 The date and time the provider decided to admit the patient
Discharge Date/Time 16.16 The date and time of the patient discharge
Facility ID 16.17 The identifier used to identify the facility. If a National Facility Identifier is used, this is a unique identification number, including when necessary the assigning authority, issued to healthcare facilities in the United States
Facility Name 16.18 The name of the facility where the encounter occurred
Facility Address 16.19 The address of the facility where the encounter occurred C154-[DE-16.19-1] The state part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.1 State C154-[DE-16.19-2] The postal code part of an address in the United States SHALL be recorded using HITSP/C80 Section 2.2.1.1.2 Postal Code C154-[DE-16.19-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
In Facility Location Duration 16.20 The duration for which a patient is at a specific
Procedure ID 17.01 An identifier for this Procedure
Procedure Type 17.02 This is a coded value describing the type of the Procedure
Procedure Free Text Type 17.03 Free text describing the Procedure
Procedure Date/Time 17.04 The date and time of the Procedure, including duration if pertinent
Procedure Provider 17.05 Name and other information for the person or organization performed or hosted the Procedure
Body Site 17.06 The anatomical site where a procedure is performed C154-[DE-17.06-1] The Site SHALL be coded as specified in HITSP/C80 Section 2.2.3.2.1 Body Site
Pedigree 18.01 A pedigree is a graphic, visual presentation of a family's health history and genetic relationships for the purpose of health risk assessment. It can provide a mechanism to identify the distribution of a medical condition or a related condition in a group of close relatives. If the condition or related condition clusters among relatives or follows a clear pattern of inheritance, then the risk for the condition can be assessed for the unaffected family members. It is important that the structured data from which the pedigree is derived also be present, because identification of inherited conditions can be complex requiring clinical decision support algorithms
Family Member Information 18.02 Family member information, including demographic data, health history, genetic test results, and relationships to other family members
Family Member Demographics 18.03 Demographic information for the family member
Family Member Relationship 18.04 Relationship of Family Member to Patient or other Family Member. Record information on relatives including 1st and 2nd degree, such as: Mother Siblings Children Aunts/uncles Cousins Grandchildren Nieces/Nephews. This data element also allows the recording of the natural father and mother, and the adoptive status. Consanguinity can be determined by including relationships between consanguineous individuals. Note: In order to record information for 3rd degree relatives and beyond, implementations can provide recursive entries. For example, the first entry could state a "grandmother", then the next entry could state the "grandmother's mother" which would be a 3rd degree relative. This enables any degree on relatives. Note: In order to record information for 3rd degree relatives and beyond, implementations can provide recursive entries. For example, the first entry could state a "grandmother", then the next entry could state the "grandmother's mother" which would be a 3rd degree relative. This enables any degree on relatives
Family Member Relationship Free Text 18.05 Free Text Data Entry for each relative used to note special cases. Examples include gamete donor and/or surrogate mother
Family Member Identifier 18.06 An identifier used to track the family member in communications between systems
Family Member Name 18.07 The name of the Family Member, used to distinguish family members textually, and need not be the actual legal name of the family members
Family Member Date of Birth 18.08 Date of Birth of Family Member
Family Member Race 18.09 Race is usually a single valued term that may be constant over that patient's lifetime. The coding of race is aligned with public health and other Federal reporting standards of the CDC and the Census Bureau C154-[DE-18.09-1] Race SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.7 Race
Family Member Ethnicity 18.10 Ethnicity is a term that extends the concept of race. The coding of ethnicity is aligned with public health and other Federal reporting standards of the CDC and the Census Bureau C154-[DE-18.10-1] Ethnicity SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.2 Ethnicity
Family Member Medical History 18.11 Information including current and past problems the family member, and genetic test results
Family Member Condition 18.12 Condition is the generic term used in the model to designate conditions, problems, diagnoses, etc C154-[DE-18.12-1] The problem type SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.2 Problem Type. C154-[DE-18.12-2] The problem SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.1 Problem
Family Member Age (at Onset) 18.13 The age (real or approximate) of the family member at the onset of the illness
Family Member Cause of Death 18.14 An indicator that a particular problem was the cause of death of the family member
Family Member Age (at Death) 18.15 The age (real or approximate) of the family member at death
Family Member Biological Sex 18.16 The biological sex of the Family Member. To be used when Administrative Sex (male/female) is not adequate to describe the family member's sex
Family Member Multiple Birth Status 18.17 Specifies if the family member is a twin, triplet etc and whether identical or fraternal
Family Member Genetic Test Information 18.18 Information about genetic test results for family members C154-[DE-18.18-1] Components of a Genetic Laboratory Test SHALL be coded as specified in HITSP/C80 Section 2.2.3.11 Genetic Testing
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