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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.

Download an Excel spreadsheet containing all C154 Data Element Information with values.
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SortData Elements
Identifier Sort
Definition Sort
Constraints Sort
Family Member Genetic Test Code 18.19 The code for the genetic lab test
Family Member Genetic Test Name 18.20 The name of the genetic lab test
Family Member Genetic Test Result 18.21 The result produced by the genetic lab test
Family Member Genetic Test Date 18.22 The date of the genetic lab test
Family Member Age 18.23 The real or approximate age of the family member
Family Member Administrative Gender 18.24 The Administrative Gender is used to refer to administrative sex rather than biological sex and therefore should easily be classified into female and male. Biological sex is recorded separately when necessary C154-[DE-18.24-1] Gender SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.1 Administrative Gender
Family Member Problem Status 18.25 The status of the family member's problem (i.e., Active, Inactive, Resolved) C154-[DE-18.23-1] The problem SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.8 Problem Status
Family Member Multiple Birth Order 18.26 Indicates the ordinal position of the family member in their order of birth in a multiple birth
Social History Date 19.01 This is the range of time of which the social history event was active for the patient or subject
Social History Type 19.02 This is a coded value indicating the type of social history observation C154-[DE-19.02-1] The Social History type SHALL be coded as specified in HITSP/C80 Section 2.2.2.4 Social History Type
Social History Free Text 19.03 This is a text description of the social history
Social History Observed Value 19.04 A value describing the social history
Language 2.01 Language will be identified as spoken, written, or understood; but no attempt will be made to assess proficiency. The default language is English, but English is to be entered explicitly similar to any other listed language C154-[DE-2.01-1] Language SHALL be coded as specified in HITSP/C80 Section 2.2.1.2.9 Language C154-[DE-2.01-2] Sign language SHALL be treated as a separate language
Discharge Instructions 22.01 Discharge instructions provide the patient with education on expected progression of illness or injury, treatment and care use of medications and follow-up
Sponsor ID 23.01 A unique identifier for a Protocol Sponsor or Study Sponsor taking responsibility for the clinical research, The Sponsor may be an individual, a company, an institution or organization
Protocol Study ID 23.02 A unique identifier for a clinical research study within a submission
Study Site ID 23.03 A unique identifier for the clinical research site for a given clinical study. This identifier is not unique outside of the context of a given clinical research study
Investigator ID 23.04 A unique identifier for the clinical researcher who oversees all aspects of the study at the study site
Order Group Number 24.01 An order group is a list of orders associated with an -placer group number. A group is established when the placer supplies a placer group number with the original order
Order Status 24.02 Report the status of an order either upon request or when the status changes
Parent Order Number 24.03 The Order number of the Parent Order which may have spawned Child orders. Used to maintain the original connection of the original order
Date Time of Transaction 24.04 The date and time of the order transaction
Order Entered By 24.05 The identity of the person who actually keyed the request into the order application (may include both a name and/or an identifier)
Order Verified By 24.06 The identity of the person who verified the accuracy of the entered request (may include both a name and/or an identifier)
Order Setting Type 24.07 Indicates the care setting in which the order is executed
Requested Order Start Date/Time 24.08 The date/time when the ordering provider is requesting the execution of orders
Order Priority 24.09 The priority of the order
Placer Order Number 24.10 The order identifier from the perspective of the system placing the order
Filler Order Number 24.11 The order identifier from the perspective of the system fulfilling the order
Order Code 24.12 The order code for the requested observation, test, and/or battery. Note: This can be based on local and/or standardized order codes
Specimen Action 24.13 Identifies the action to be taken with respect to the specimens that accompany or precede this order. The purpose of this field is to further qualify (when appropriate) the general action indicated by the order
Ordering Provider 24.14 The person that wrote this order (may include both a name and an identifier)
Results Distribution List 24.15 Identifies the people and/or organization that are to receive copies of the results
Specimen Collector ID 24.16 The person, department, or facility that collected the specimen. (may include both a name and an identifier)
Specimen ID 25.01 An identifier for this specific Specimen
Specimen Parent ID 25.02 The identifiers for the specimen or specimens that contributed to the specimen
Specimen Type 25.03 The precise nature of the specimen observed/received
Specimen Collection Method 25.04 Describes the procedure or process by which the specimen was collected
Specimen Source Site 25.05 Specifies the source from which the specimen was obtained. For example, in the case where a liver biopsy is obtained via a percutaneous needle, the source would be 'liver'
Specimen Source Site Modifier 25.06 Modifies or qualifies description(s) about the specimen type
Specimen Risk 25.07 Describes any known or suspected specimen hazards, e.g., exceptionally infectious agent or blood from a hepatitis patient
Specimen Collection Date/Time 25.08 The date and time when the specimen was acquired from the source. The use of the Date Range data type allows for description of specimens collected over a period of time, for example, 24-hour urine collection
Specimen Received Date/Time 25.09 The date/time that the specimen is received at the diagnostic service
Specimen Availability 25.10 Describes whether the specimen, as it exists, is currently available to use in an analysis
Specimen Rejection Reason 25.11 Describes a reason for which the specimen is being rejected for the specified observation/result/analysis
Number of Specimen Containers 25.12 The number of containers for a given sample. (For sample receipt verification purposes; this may be different from the total number of samples that accompany the order)
Date 3.01 The period over which the support is provided Table 2-8 Support Data Mapping Table - Definitions: Contact Identifier Name Definition Constraints
Contact Type 3.02 This represents the type of support provided, such as immediate emergency contacts, next of kin, family relations, guardians, agents, etc
Contact Relationship 3.03 Identifies the relationship of the contact person to the individual for which this exchange refers C154-[DE-3.03-1] The contact relationship SHALL have be coded as specified in HITSP/C80 Section 2.2.1.2.4 Personal Relationships
Contact Address 3.04 The address of the contact individual or organization providing support to the individual for which this exchange is produced C154-[DE-3.04-1] 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-3.04-2] 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-3.04-3] The country part of an address SHALL be recorded using HITSP/C80 Section 2.2.1.1.3 Country
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