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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
Pregnancy 9.01 This is a simple observation that records whether the patient is currently pregnant
Fill Status 8.40 Fulfillment History Component. The fill event status is typically 'complete' indicating the fill event has been, or is expected to be picked up. A status of 'aborted' indicates that the dispense was never picked up (e.g., "returned to stock")
Fill number 8.39 Fulfillment History Component: The fill number for the history entry. Identifies this dispense as a distinct event of the prescription
Quantity Dispensed 8.38 Fulfillment History Component: The actual quantity of product supplied in this dispense. Note: This is comprised of both a numeric value and a unit of measure
Dispense Date 8.37 Fulfillment History Component: The date of this dispense
Dispensing Pharmacy Location 8.36 (Previously known as Location)
Dispensing Pharmacy (previously known as Provider) 8.35 Fulfillment History Component: The pharmacy that performed this dispense (may include both a name and an identifier)
Prescription Number 8.34 Fulfillment History Component: The prescription identifier assigned by the pharmacy
Fulfillment History 8.33 History of dispenses for this order. Comprised of Fulfillment History Components
Fulfillment Instructions 8.32 Instructions to the dispensing pharmacist or nurse that are not traditionally part of the Sig. For example, "instruct patient on the use of occlusive dressing"
Ordering Provider 8.31 The person that wrote this order/prescription (may include both a name and an identifier)
Order Date/Time 8.30 The date, including time if available, when the ordering provider wrote the order/prescription
Order Expiration Date/Time 8.29 The date, including time if applicable, when the order is no longer valid. Dispenses and administrations are not continued past this date for an order instance
Quantity Ordered 8.28 The amount of product indicated by the ordering provider to be dispensed. For example, number of dosage units or volume of a liquid substance. Note: this is comprised of both a numeric value and a unit of measure
Fills 8.27 The number of times that the ordering provider has authorized the pharmacy to dispense this medication
Order Number 8.26 The order identifier from the perspective of the ordering clinician. Also known as the 'placer number' versus the pharmacies prescription number (or 'filler number')
Dose Indicator 8.25 A Sig Component: A criteria that specifies when an action is, or is not, to be taken. For example, "if blood sugar is above 250 mg/dl"
Vehicle 8.24 A Sig Component: Non-active ingredient(s), or substances not of therapeutic interest, in which the active ingredients are dispersed. Most often applied to liquid products where the major fluid component is considered the vehicle. For example: Normal Saline is the vehicle in "Ampicillin 150mg in 50ml NS"; Aquaphor is the vehicle in "10% LCD in Aquaphor" C154-[DE-8.24-1] The Vehicle shall be coded as specified in HITSP/C80 Section 2.2.3.3.12 Medication Vehicle
Reaction 8.23 Any noted intended or unintended effects of the product. For example: full body rash, nausea, rash resolved
Patient Instructions 8.22 Instructions to the patient that are not traditionally part of the Sig. For example, "keep in the refrigerator." More extensive patient education materials can also be included
Indication 8.21 A Sig Component: The medical condition or problem intended to be addressed by the ordered product. For example: for chest pain, for pain, for high blood pressure C154-[DE-8.21-1] The indication SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.1 Problem
Status of Medication 8.20 If the medication is Active, Discharged, Chronic, Acute, etc C154-[DE-8.20-1] The medication status MAY be recorded using the CCD Medication Status observation using the value set defined in the CCD
Type of Medication 8.19 A classification based on how the medication is marketed (e.g., prescription, over the counter drug) C154-[DE-8.19-1] The type of medication SHALL be coded as specified in HITSP/C80 Section 2.2.3.3.5 Medication Type
Product Concentration 8.18 The amount of active ingredient, or substance of interest, in a specified product dosage unit, mass or volume. For example 250 mg per 5 ml Note: "Product dosage unit" provides for describing the "concentration" of a physical form. For example, 800 mg per 1 tablet. In this manner, this data element may also be known as Product Strength. This may be implicit in the product as named or as a codified product.
Drug Manufacturer 8.17 The manufacturer of the substance or product as ordered or supplied. The distributor may be supplied if the manufacturer is not known
Free Text Brand Name 8.16 The branded or trademarked name of the substance or product. If a Coded Brand Name is present, this is the text associated with the coded concept C154-[DE-8.16-1] This MAY include additional information such as strength, dose form, etc
Free Text Product Name 8.15 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-8.15-1] 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
Coded Brand Name 8.14 A code describing the product as a branded or trademarked entity from a controlled vocabulary C154-[DE-8.14-1] The brand name SHALL be coded as specified in HITSP/C80 Section 2.2.3.3.7 Medication Brand Name or 2.2.3.3.10 Medication Packaged Product.
Coded Product Name 8.13 A code describing the product from a controlled vocabulary C154-[DE-8.13-1] The coded product name SHALL be coded as specified in HITSP/C80 Section 2.2.3.3.8 Medication Clinical Drug Names. C154-[DE-8.13-2] When only the class of the drug is known (e.g., Beta Blocker or Sulfa Drug), it SHALL be coded as specified in HITSP/C80 Section 2.2.3.3.9 Medication Drug Class. C154-[DE-8.13-3] When only the medication ingredient name is know, the coded product name MAY be coded as specified in HITSP/C80 Section 2.2.3.3.11 Ingredient Name
Delivery Method 8.12 A Sig Component: A description of how the product is administered/consumed
Product Form 8.11 The physical form of the product as presented to the patient. For example: tablet, capsule, liquid or ointment C154-[DE-8.11-1] SHALL be coded as specified in HITSP/C80 Section 2.2.3.3.3 Medication Product Form
Dose Restriction 8.10 A Sig Component: defines a maximum or dose limit. This segment can repeat for more than one dose restriction
Site 8.09 A Sig Component: The anatomic site where the medication is administered. Usually applicable to injected or topical products C154-[DE-8.09-1] The Site SHALL be coded as specified in HITSP/C80 Section 2.2.3.2.1 Body Site
Dose 8.08 A Sig Component: the amount of the product to be given. This may be a known, measurable unit (e.g., milliliters), an administration unit (e.g., tablet), or an amount of active ingredient (e.g., 250 mg). May define a variable dose, dose range or dose options based upon identified criteria (see Dose Indicator) C154-[DE-8.08-1] Units MAY be present when needed. If present it SHALL be coded as specified in HITSP/C80 Section 2.2.3.6.6 Units of Measurement C154-[DE-8.08-2] When the coded product or brand name describes the strength or concentration of the medication, and the dosing is in administration units (e.g., 1 tablet, 2 capsules), units SHOULD contain the preferred name of the presentation units within braces { } using the units of presentation from the NCI Thesaurus
Route 8.07 A Sig Component: indicates how the medication is received by the patient (e.g., by mouth, intravenously, topically, etc.) C154-[DE-8.07-1] SHOULD be coded using value sets consistent with those specified in HITSP/C80 Section 2.2.3.3.4.1 Medication Route FDA1
Duration 8.06 A Sig Component: for non-instantaneous administrations, indicates the length of time the administration should be continued. For example, (infuse) over 30 minutes
Interval 8.05 A Sig Component: defines how the product is to be administered as an interval of time. For example, every 8 hours. Complimentary to Frequency, although equivalent expressions may have different implications (e.g., every 8 hours versus 3 times a day)
Frequency 8.04 A Sig Component: defines how often the medication is to be administered as events per unit of time. Often expressed as the number of times per day (e.g., four times a day), but may also include event-related information (e.g., 1 hour before meals, in the morning, at bedtime). Complimentary to Interval, although equivalent expressions may have different implications (e.g., every 8 hours versus 3 times a day)
Administration Timing 8.03 A Sig Component: defines a specific administration or use time. Can be a text string (Morning, Evening, Before Meals, 1 Hour After Meals, 3 Hours After Meals, Before Bed) or an exact time
Indicate Medication Stopped 8.02 A Sig Component: Used to express a "hard stop," such as the last Sig sequence in a tapering dose, where the last sequence is 'then D/C' or where the therapy/drug is used to treat a condition and that treatment is for a fixed duration with a hard stop, such as antibiotic treatment, etc
Free Text Sig 8.01 The instructions, typically from the ordering provider, to the patient on the proper means and timing for the use of the product. This information is free-text but can also be represented as a series of Sig Components
Problem Status 7.12 The status of the problem (active, inactive, resolved) C154-[DE-7.12-1] The problem SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.8 Problem Status
Treating Provider ID 7.11 The identifier assigned the treating provider (National Provider ID)
Diagnosis Priority 7.10 A number indicating the significance or the priority of the diagnosis code. It is used to distinguish between the primary and other diagnoses C154-[DE-7.10-1] The problem SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.4 Diagnosis Priority
Time of Death 7.09 The date/time the patient or subject's death occurred
Age (at Death) 7.08 The age of the patient or subject at death
Cause of Death 7.07 Indicates that this problem was one of the causes of death for the patient or subject of the condition
Age (at Onset) 7.06 The age of the patient or subject at onset of the condition
Treating Provider 7.05 The provider or providers treating the patient or subject for this condition
Problem Code 7.04 This value is a code describing the problem according to a specific vocabulary of problems C154-[DE-7.04-1] The problem SHALL be coded as specified in HITSP/C80 Section 2.2.3.1.1 Problem
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