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HITSP/C80: HITSP Clinical Document and Message Terminology Component


1. Introduction

1.1 Overview

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.

1.2 Copyright Permissions

COPYRIGHT NOTICE
© 2010 ANSI. 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 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.

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


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.

2.1.1 Value Set Metadata

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

2.2 Rules for Implementing Value Sets

The use of this construct is defined by the Component, Transaction, Transaction Package, Capability or Interoperability Specification that may refer to it

2.2.1 General Information Value Sets

See Value Sets: State, Postal Code, and Country Value Sets for details

2.2.1.2 Demographic Information Value Sets

See Value Sets: Gender, Ethnicity, Marital Status, Personal Relationship, Family Relationship, Contact, Race, Religious Affiliation, Language, Language Ability for details

2.2.2 Administration and Financial Value Sets

See Value Sets: Health Insurance Type, Subscriber Relationship, Financially Responsible Party, Social History for details

2.2.3 Care Management and Health Record Value Sets

See Value Sets: Problem, Problem Type, Diagnosis Type, Diagnosis Priority, Nursing Diagnosis, Problem Severity, Functional Assessment, Problem Status for details

2.2.3.2 Body Site

See Value Sets: Body Site for details

2.2.3.3 Medications

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

2.2.3.3.2 Medication Indication

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

2.2.3.3.4 Medication Route

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

2.2.3.3.6 Medication Site

This is the anatomic site where the medication is administered. See 2.2.3.1.8 Body Site for details

2.2.3.4 Allergies

See Value Sets: Allergy/Adverse Event Type for details

2.2.3.4.1 Allergy/Adverse Event (Reaction)

This indicates the reaction that may be caused by the product or agent. See 2.2.3.1.1 Problem for details

2.2.3.4.3 Allergy/Adverse Event Severity

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

2.2.3.4.4 Allergy/Adverse Event Product

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

2.2.3.5 Immunizations

See Value Sets: Vaccine Administered, Vaccine Manufacturer, No Immunization Reason, Immunization Information Source, Immunization Service Funding Eligibility for details

2.2.3.6 Measurements and Laboratory Results

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

2.2.3.6.1 Laboratory Observation

This identifies laboratory results. See Laboratory observation identifier, Laboratory Finding Identifier, Laboratory Order for details

2.2.3.6.4 Result Status

This identifies the status for the results (observation). See V2 Result Status Code System, V3 Result Status for details

2.2.3.7 Procedures

See Value Sets: Procedure for details

2.2.3.8 Providers

See Value Sets: Provider Role, Provider Type for details

2.2.3.9 Admissions and Encounters

See Value Sets: Admission Source, Admission Type, Encounter Type, Discharge Disposition, Patient Class for details

2.2.3.10 Advance Directives

See Value Sets: Advance Directive Type for details

2.2.3.11 Genetic Testing

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

2.2.3.12 Genetic Disease

This identifies genetic diseases. See Value Set 2.2.3.1.1 Problems for details

2.2.3.13 Medication Assessed in Genetic Test

This identifies the medication assessed for the genetic test. See Value Set 2.2.3.3.8 Medication Clinical Drug Name for details

2.2.3.15 Document Metadata

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

Download an Excel spreadsheet containing all C80 Value Set Information with values.
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SortValue Sets:
OID Sort
Purpose Sort
Administrative Gender Value Set 2.16.840.1.113883.1.11.1 Demographic Information
Admission Source Value Set 2.16.840.1.113883.3.88.12.80.33 This indicates where the patient was admitted from
Admission Type Value Set 2.16.840.1.113883.3.88.12.80.33 A code indicating the priority of the admission (e.g., Emergency, Urgent, Elective, et cetera)
Advance Directive Type Value Set 2.16.840.1.113883.1.11.20.2 This identifies the type of the Advance Directive
Allergy/Adverse Event Type Value Set 2.16.840.1.113883.3.88.12.3221.6.2 This describes the type of product and intolerance suffered by the patient
Author Role Value Set 2.16.840.1.113883.3.18.6.1.15 This is the code specifying the role of the document author when the document was created.
Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 Identify the body site for injury, specimen, injection and finding
Clinical Specialty Value Set 2.16.840.1.113883.3.88.12.80.72 This is the code representing the clinical specialty of the clinician or provider who interacted with, treated, or provided a service to/for the patient
Confidentiality Value Set 2.16.840.1.113883.1.11.10228 This is the code specifying the level of confidentiality of the document, which may be used by IT systems to make an authorization decision about access to the document. More than one value may be applied to any document
Contact Type Value Set 2.16.840.1.113883.3.88.12.3221.3.2 Demographic Information
Country Value Set 2.16.840.1.113883.3.88.12.80.63 This identifies the codes for the representation of names of countries, territories and areas of geographical interest. Note: This table provides the ISO 3166-1 code elements available in the alpha-2 code of ISO's country code standard.
Coverage Role Type Value Set 2.16.840.1.113883.1.11.18877 Describes the role recognized through the issuance of insurance coverage to an identified covered party who has this relationship with the policy holder such as the policy holder themselves (self), spouse, child, etc.
Diagnosis Priority Value Set 2.16.840.1.113883.3.88.12.80.4 Problems and Diagnosis
Diagnosis Type Value Set 2.16.840.1.113883.3.88.12.80.3 This identifies the type of diagnosis being used
Discharge Disposition Value Set 2.16.840.1.113883.3.88.12.80.33 This is the patient's anticipated location or status following the encounter (e.g., death, transfer to home/hospice/snf/AMA) - uses standard claims-based codes
Document Class Value Set 2.16.840.1.113883.3.88.12.80.46 This is the code specifying the particular kind of document (e.g., Prescription, Discharge Summary, Report, etc.). It is suggested that the XDS Affinity Domain draws these values from a coding scheme providing a coarse level of granularity (about 10 to 100 entries)
Document Type Value Set 2.16.840.1.113883.3.88.12.80.47 This is the code specifying the precise type of document (e.g., Pulmonary History and Physical, Discharge Summary, Ultrasound Report, etc.). It is suggested that the XDS Affinity Domain draw these values from a coding scheme providing a fine level of granularity
Encounter Type Value Set 2.16.840.1.113883.3.88.12.80.32 This is used to identify medical services and procedures furnished by physicians and other healthcare professionals
Ethnicity Value Set 2.16.840.1.113883.1.11.15836 Demographic Information
Family Member Value Set 2.16.840.1.113883.1.11.19579 Demographic Information
Financially Responsible Party Type Value Set 2.16.840.1.113883.1.11.10416 This identifies the party that has responsibility for all or a portion of the patient's healthcare; includes health insurance, the patient directly, a guardian or other guarantor, or other third party that is not a health insurance plan
Format Code Value Set 2.16.840.1.113883.3.88.12.80.73 This is the code specifying the format of the document. Along with the typeCode, it should provide sufficient information to allow any potential document consumer to know if it will be able to process the document. The code shall be sufficiently specific to ensure processing/display by identifying a document encoding, structure and template
Functional Assessment Value Set 2.16.840.1.113883.3.88.12.80.61 Problems and Diagnosis
Genetic Reference Sequence Value Set 2.16.840.1.113883.3.88.12.80. This identifies genetic reference sequences
Genetic Sequence Variation Value Set 2.16.840.1.113883.3.88.12.80.43 This provides description of genetic sequence variations
Genetic Test Result Identifier Value Set 2.16.840.1.113883.3.88.12.80.34 This identifies different components of the test result
Genetic Test Result Value Set 2.16.840.1.113883.3.88.12.80.35 This identifies the genetic test results
Gene Name Value Set 2.16.840.1.113883.3.88.12.80.37 This identifies gene names
Healthcare Facility Type Value Set 2.16.840.1.113883.3.88.12.80.67 This is the code representing the type of organizational setting where the clinical encounter,, service, interaction, or treatment occurred
Health Insurance Type Value Set 2.16.840.1.113883.3.88.12.3221.5.2 Identify the types of insurance plans or programs covering a patient's care.
Immunization Information Source 2.16.840.1.113883.3.88.12.80.39 This identifies the source of information for this immunization record or, more generically, whether the immunization being reported has just been administered (new) or came from other records (historical)
Immunization Service Funding Eligibility Value Set 2.16.840.1.114222.4.5.301 Identifies the Immunization Service Funding Eligibility assigned to the patient for the purpose of identifying sources of reimbursement
Ingredient Name Value Set 2.16.840.1.113883.3.88.12.80.20 This identifies drug ingredients, such as Gentian violet
Laboratory Finding Identifer Value Set 2.16.840.1.113883.3.88.12.80.24 These values are used in laboratory results to report the specific findings
Laboratory Observation Identifier Value Set 2.16.840.1.113883.3.88.12.80.40 This identifies the particular laboratory result being reported upon in a lab test
Laboratory Order Value Set 1.3.6.1.4.1.12009.10.2.2 This identifies the laboratory order
Language Ability Mode Value Set 2.16.840.1.113883.1.11.12249
Language Value Set 2.16.840.1.113883.1.11.11526 This identifies the name of a human language.
Marital Status Value Set 2.16.840.1.113883.1.11.12212 Demographic Information
Medication Brand Name Value Set 2.16.840.1.113883.3.88.12.80.16 This identifies the product brand name of drugs, such as Tylenol, Claritin, etc.
Medication Clinical Drug Name Value Set 2.16.840.1.113883.3.88.12.80.17 Medication Clinical Drug Name
Medication Drug Class Value Set 2.16.840.1.113883.3.88.12.80.17 This identifies the pharmacological drug class, such as Cephalosporins
Medication Fill Status Value Set 2.16.840.1.113883.3.88.12.80.64 Medication
Medication Packaged Product Value Set 2.16.840.1.113883.3.88.12.80.19 This identifies the labeler, product, and trade package size, such as Tylenol 325 mg tablet bottle of 100
Medication Product Form Value Set 2.16.840.1.113883.3.88.12.3221.8.11 Medication - Dosage Forms
Medication Route FDA Value Set 2.16.840.1.113883.3.88.12.3221.8.7 Medication Administration Route
Medication Type Value Set 2.16.840.1.113883.3.88.12.3221.8.19 This is a classification based on how the medication is marketed (e.g., prescription, over the counter drug)
Medication Vehicle Value Set 2.16.840.1.113883.3.88.12.80.21 This indicates 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
Newborn Screening Order Value Set 1.3.6.1.4.1.12009.10.2.1 This identifies the newborn screening order
Newborn Screening Results - Observation and Findings Value Set 1.3.6.1.4.1.12009.10.2.1 This identifies the newborn screening results - observation and findings
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