The purpose of the Health Information Technology Standards Panel (HITSP) Clinical Document and Message Terminology Component is to define the vocabulary for either document-based or message-based HITSP constructs such as Clinical Document Architecture (CDA) documents, HL7 V2 messages, etc. For more in-depth information about how this Component relates to other HITSP constructs, see HITSP/TN901 Clinical Documents.
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Certain materials contained in this Interoperability Specification are reproduced from HL7 Version 3 Standard: Core Principals 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 Interoperability Specification may be purchased from the Health Level Seven, Inc. Material drawn from these standards is credited where used.
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  [publicaa.ansi.org] |
Lists and defines the acronyms used in this document |
| HITSP Glossary [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 |
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.
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.
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.
The Value Sets in this document are defined in a table as shown below.
| Element | Description |
|---|---|
| Identifier | This is the unique identifier of the value set |
| Name | This is the name of the Value Set |
| Source | This is the source of the Value Set, identifying the originator or publisher of the information |
| URL | A URL referencing the Value Set members or its definition at the time of publication |
| Purpose | Brief description about the general purpose of Value Set |
| Definition | A text definition formally describing how concepts in the Value Set are (intensional) or were (extensional) selected |
| Version | This row contains a string identifying, where necessary, the specific version of the Value Set |
| Type | Extensional (Enumerated) or Intensional (Criteria-based) |
| Binding | Static or Dynamic |
| Status | Active (Current) or Inactive (Retired) |
| Effective Date | The date when the Value Set is expected to be effective |
| Expiration Date | The date when the Value Set is no longer expected to be used |
| Creation Date | The date of creation of the Value Set |
| Revision Date | The date of revision of the Value Set |
| Code System Source | This row identifies the source for the code system |
| Code System Name | This row provides the name of the code system associated with the Value Set |
The use of this construct is defined by the Component, Transaction, Transaction Package, Capability or Interoperability Specification that may refer to it
See Value Sets: State, Postal Code, and Country Value Sets for details
See Value Sets: Gender, Ethnicity, Marital Status, Personal Relationship, Family Relationship, Contact, Race, Religious Affiliation, Language, Language Ability for details
See Value Sets: Health Insurance Type, Subscriber Relationship, Financially Responsible Party, Social History for details
See Value Sets: Problem, Problem Type, Diagnosis Type, Diagnosis Priority, Nursing Diagnosis, Problem Severity, Functional Assessment, Problem Status for details
See Value Sets: Body Site for details
See Value Sets: Medication Fill Status, Medication Product Form, Medication Route FDA, V2 Medication Route, Medication Type, Medication Brand Name, Medication Clinical Drug Name, Medication Drug Class, Medication Packaged Product, Ingredient Name, Medication Vehicle for details
This is the medical condition or problem intended to be addressed by the ordered medication. For example: for chest pain, for pain, for high blood pressure. See 2.2.3.1.1. Problem for details
This indicates the method for the medication received by the individual (e.g., by mouth, intravenously, topically, etc). See Value Sets: Medication Route FDA, V2 Medication Route for details
This is the anatomic site where the medication is administered. See 2.2.3.1.8 Body Site for details
See Value Sets: Allergy/Adverse Event Type for details
This indicates the reaction that may be caused by the product or agent. See 2.2.3.1.1 Problem for details
This is a description of the level of the severity of the allergy or intolerance. See 2.2.3.1.6 Problem Severity for details
This identifies the product or agent that causes the intolerance. See Value Sets 2.2.3.3.11 Ingredient Name, 2.2.3.3.9 Medication Drug Class, 2.2.3.3.8 Medication Clinical Drug Name for details
See Value Sets: Vaccine Administered, Vaccine Manufacturer, No Immunization Reason, Immunization Information Source, Immunization Service Funding Eligibility for details
See Value Sets: Laboratory Observation Identifier, Laboratory Finding Identifier, Laboratory Order, Result Normalcy Status, V2 Result Status Code System, V3 Result Status, Vital Sign Result, Unit of Measure Code System, Order Control Code System, Order Status Code System, Order Setting Type Code System, Order Priority Code System, Specimen Action Code, Specimen Risk Code System, Specimen Type, Specimen Collection Method, Newborn Screening Order, Newborn Screening Results - Observation and Findings for details
This identifies laboratory results. See Laboratory observation identifier, Laboratory Finding Identifier, Laboratory Order for details
This identifies the status for the results (observation). See V2 Result Status Code System, V3 Result Status for details
See Value Sets: Procedure for details
See Value Sets: Provider Role, Provider Type for details
See Value Sets: Admission Source, Admission Type, Encounter Type, Discharge Disposition, Patient Class for details
See Value Sets: Advance Directive Type for details
The following sections describe the value sets selected for reporting the results of genetic tests. See Value Sets: Genetic Test Result Identifier, Genetic Test Result for details
This identifies genetic diseases. See Value Set 2.2.3.1.1 Problems for details
This identifies the medication assessed for the genetic test. See Value Set 2.2.3.3.8 Medication Clinical Drug Name for details
The following sections describe the value sets selected for recording document metadata in transactions used to register and exchange clinical documents. Descriptions of the value sets in this section are drawn from the IHE IT Infrastructure Technical Framework, Volume II, Release 4.0. Only those metadata elements that require coded values are listed in this section; other fields should be provided as described in the relevant base standard. See Value Sets: Document Class, Document Type, Healthcare Facility Type, Clinical Specialty, Format Code, Author Role for details
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