Standard Health Record

Code Systems defined as part of this Implementation Guide

Name Definition
AnatomicalDirectionCS

Anatomical location or specimen further detailing directionality. Codes are from NCI

AttributionCategoryCS

Whether the adverse event is attributed to a treatment, course of the disease, medical error, unrelated to either, or unknown.

BreastCancerStageCS

Codes representing the overall stage of the cancer, based on criteria defined by the staging system being used. The preferred staging system is American Joint Committee on Cancer, 8th Edition, Breast Cancer Chapter. Codes and descriptions have been redacted due to copyright restrictions.

BreastCancerTypeCS

Histologic types of breast cancer. Codes are drawn from ICD-O-3. Codes are presented as local codes due to the lack of a ICD-O-3 terminology server available to the FHIR IG publisher.

BreastSiteCS

Topography of the breast. Codes are drawn from ICD-O-3. Codes are presented as local codes due to the lack of a ICD-O-3 terminology server available to the FHIR IG publisher.

BreastSpecimenTypeCS

The type of specimen obtained from the breast.

CodingQualifierCS

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ConditionCategoryCS

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DegreeOfLymphaticInvolvementCS

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DiagnosticServiceCS

The type of laboratory service used in producing a laboratory result

EpisodeOfCareCompletionCS

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ExceptionValueCS

Reasons that a value associated with a test or other finding is missing. Includes all codes from http://hl7.org/fhir/ValueSet/data-absent-reason version 3.3.0 and additional codes covering other missing value circumstances.

HER2ISHMethodCS

Value set containing In Situ Hybridization methods of determining HER2 status

HER2StatusCS

HER2 status overall result

LanguageQualifierCS

A code indicating whether the language is preferred, secondary, or practiced in an unconventional or limited way.

MammaprintRiskScoreInterpretationCS

Intepretation of Mammaprint Recurrence Score

MedicationChangeReasonCS

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MedicationChangeTypeCS

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MedicationNotUsedReasonCS

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MilitaryServiceDischargeStatusCS

The way in which a separation from the armed services was achieved.

MilitaryServiceEraCS

Values were taken from Final HMIS Data Standards March 2010 (Homeless Management Information System), field 5.05E Veteran’s Information. See: https://www.onecpd.info/resources/documents/FinalHMISDataStandards_March2010.pdf.

MilitaryStatusCS

The current status of the person in armed services.

MitoticCountScoreCS

Value set containing the scores for Nottingham Histologic Score Mitotic Rate

MorphologyBehaviorCS

The morphologic behavior of the cancer. These are the suffix to the ICD-O-3 histologic type codes. Codes are presented as local codes due to the lack of a ICD-O-3 terminology server available to the FHIR IG publisher.

NottinghamNullCS

Data absent reasons (null values) for Nottingham Combined Grade scores. Removes non-applicable values from the ExceptionValueVS, and adds values that align with LOINC normative answer list LL4561-8

NuclearGradeCS

The nuclear grade describes how closely the nuclei of cancer cells look like the nuclei of normal breast cells. In general, the higher the nuclear grade, the more abnormal the nuclei are and the more aggressive the tumor cells tend to be. The nuclear grade is a part of overall tumor grade.

OncotypeDxDCISRiskScoreInterpretationCS

Intepretation of OncotypeDX DCIS (Ductal Carcinoma In Situ) Recurrence Score

OncotypeDxInvasiveRiskScoreInterpretationCS

Intepretation of OncotypeDX Recurrence Score for invasive cancers.

PerformanceGradingScaleCS

A simple performance grading scale. Also useful for grading quality.

QualitativeDateTimeCS

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QualitativeFrequencyCS

Code set indicating the frequency of an event in qualitative terms.

QualitativeLikelihoodCS

The likelihood of an event or state, expressed qualitatively. Qualitative likelihoods are associated with judgments and assessments. Values are based on US Intelligence Community’s standard language used to describe judgements of likelihood.

QualitativeValueScaleCS

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ReasonEncounterDidNotHappenCS

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RecurrenceRiskScoreInterpretationCS

Interpretations of risk as high, intermediate, or low. Answer set taken from LOINC LL3198-0

ReferralSourceTypeCS

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ResearchSubjectTerminationReasonCS

The reason for a research subject leaving a research study.

SemiquantitativeDurationCS

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SemiquantitativeFrequencyCS

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SettingCS

What type of place is found at a given location. More than one descriptor may be applicable.

StageTimingPrefixCS

When staging was done, relative to treatment events.

StagingMethodCS

The methodology or standard used to assign the cancer’s overall stage.

StainingIntensityCS

Part of the Allred scoring, based on the intensity of that staining, on a scale of 0 (Negative) to 3 (Strong).

StudyArmTypeCS

The role of each arm in the clinical trial.

TelecomQualifierCS

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ThreePriorityCS

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TreatmentCooperationCS

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USMilitaryBranchCS

The code indicating the branch of the US military.

YesNoCS

Code set indicating yes or no.

YesNoUnknownCS

Code set indicating yes, no, or unknown.