Standard Health Record FHIR Implementation Guide

Extensions defined for this Guide

SHR Namespace Name Definition
Primitive base64Binary The base64Binary that represents the value of the SHR element to which it is applied.
Primitive boolean The boolean that represents the value of the SHR element to which it is applied.
Primitive code The code that represents the value of the SHR element to which it is applied.
Primitive date The date that represents the value of the SHR element to which it is applied.
Primitive dateTime The dateTime that represents the value of the SHR element to which it is applied.
Primitive decimal The decimal that represents the value of the SHR element to which it is applied.
Primitive id The id that represents the value of the SHR element to which it is applied.
Primitive instant The instant that represents the value of the SHR element to which it is applied.
Primitive integer The integer that represents the value of the SHR element to which it is applied.
Primitive markdown The markdown that represents the value of the SHR element to which it is applied.
Primitive oid The oid that represents the value of the SHR element to which it is applied.
Primitive positiveInt The positiveInt that represents the value of the SHR element to which it is applied.
Primitive string The string that represents the value of the SHR element to which it is applied.
Primitive time The time that represents the value of the SHR element to which it is applied.
Primitive unsignedInt The unsignedInt that represents the value of the SHR element to which it is applied.
Primitive uri The uri that represents the value of the SHR element to which it is applied.
Primitive xhtml The xhtml that represents the value of the SHR element to which it is applied.
Action Action An entry related to an action or intervention, whether potential or actual, past or future. An intervention is an action addressing a undesired health state, behavior, risk, or goal.
Action ActionContext The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Action CommunicationMethod This is the method the provider used to communicate. Examples include: Written, Telephoned, Verbal, Electronically Entered, Policy, Service Correction, Duplicate, etc. 'Code indicating the origin of the prescription.' - NCPDP Telecommunication (Field 419-DJ, Data Dictionary 201104). Possible values include: Written; Telephone; Electronic; Facsimile; Pharmacy; Not Known.
Action ExpectedMethod The method that should be used to carry out the action.
Action ExpectedPerformanceTime When an action should be done. If the action is a series or recurs (e.g. daily blood sugar testing in the morning) then a Timing can be used to describe the periodicity.
Action ExpectedPerformer Who should carry out the tests. For example, the patient or caregiver.
Action ExpectedPerformerType What type of party should carry out the testing.
Action Method The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
Action NotPerformedContext A record that a clinical act was not performed at a certain time or during a stated period of time, particularly when there might be an expectation of performing such an act, for example, if a vaccination is not given because of parental objection. Do not use this context if the act was initiated or started but aborted or cancelled.
Action Outcome The result of performing an action or behavior, for example, an adverse reaction or new finding.
Action Participant An object (usually a Person, Party, or Organization but potentially a device or other Entity) that participates in a task or activity.
Action ParticipationPeriod The point in time or span of time the participant is involved.
Action ParticipationType The role played by the participant engaged in the action, for example, as the attending physician, surgical assistant, etc.
Action PatientInstructions Information for the patient, such as, where to get the test, how to prepare for the test, etc.
Action PerformedContext ActionContext indicating actual performance or execution of a healthcare-related action, e.g., 3rd dose of Hepatitis B vaccine administered on Dec 4th 2012, appendectomy performed today.
Action PerformerInstructions Information for the performer of the test, if needed.
Action RelatedPlan The plan that this action fulfills
Action RelatedRequest The request that this action fulfills
Action RequestIntent Indicates the level of authority/intentionality associated with the request and where the request fits into the workflow chain.
Action RequestedAgainstContext Represents a recommendation or order from a practitioner or clinical decision support system to NOT perform an act.
Action RequestedContext An order for something to take place.
Action Status Position in workflow.
Adverse ActionTaken The action taken as a result of the adverse reaction. May include changing or discontinuing medication, reducing dose, etc.
Adverse AdverseEventGrade A coded value specifying the level of injury suffered by the subject for whom the event is reported, using the CTCAE coding system.
Adverse CauseCategory Whether the adverse event is attributed to a treatment, course of the disease, unrelated to either, or unknown.
Base Author The person or organization who created the entry and is responsible for (and may certify) the content.
Base Content An item that can constitute the payload of an Entry, aka an EntryElement.
Base Informant The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.
Base Language A human language, spoken or written.
Base PersonOfRecord The person this record belongs to.
Base RelatedEncounter If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Base ShrId A unique, persistent, permanent identifier for the overall health record belonging to the PersonOfRecord.
Base Subject The person or thing that this entry relates to, usually the Person of Record. However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, finding, condition, or intervention.
Behavior ReadinessToChange How motivated the subject is to change the behavior, if the behavior is ongoing, and change would be beneficial.
Behavior ReasonForBehavior Why the behavior has taken or is taking place.
Careplan ActualActivities Activites carried out for this goal
Careplan Goal A broad statement about what should be accomplished for or by a patient or other subject. It represents the intended long-term outcome toward which an individual or a group aspires, and toward which, effort is directed, in the form of activities.
Careplan PlannedActivities Activites planned for this goal
Condition Abatement The end, remission or resolution.
Condition Criticality The potential clinical harm associated with a condition. When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.
Condition Preexisting If the problem or condition existed before the current episode of care.
Condition WhenClinicallyRecognized The time at which a condition or condition was first identified in a healthcare context.
Core Address An address expressed using postal conventions (as opposed to GPS or other location definition formats). This data type may be used to convey addresses for use in delivering mail as well as for visiting locations and which might not be valid for mail delivery. There are a variety of postal address formats defined around the world. (Source: HL7 FHIR).
Core Age How long something has existed in time.
Core AgeGroup Subgroups of populations based on age.
Core AgeRange A quantitative range of ages. One of the two ages must be specified.
Core Annotation An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
Core Category A class or division of people or things having particular shared characteristics
Core ClockDirection A direction indicated by an angle relative to 12 o'clock.
Core CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
Core ContactPoint An electronic means of contacting an organization or individual.
Core Country Country - a nation as commonly understood or generally accepted, expressed in ISO 3166 Alpha-2 (2-letter) codes.
Core CreationTime The point in time when the information was recorded in the system of record.
Core Details An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
Core Distance The measure of space separating two objects or points.
Core EffectiveTimePeriod The date and time span for which something is active, valid, or in force.
Core GeneralizedAge Qualitative or quantitative, exact or inexact description of age.
Core GeneralizedDateTime A point in time, specified qualitatively or quantitatively.
Core GeneralizedTemporalContext A generalized indicator of a dateTime or an age when an event happened.
Core GeopoliticalLocation The countries of the world and major geopolitical subregions, such as US states.
Core Geoposition The location on the surface of the Earth, described by a latitude and longitude (and optional altitude).
Core GestationalAge The age of the embryo or fetus. This may be assessed by medical history, physical examination, early immunologic pregnancy tests, radiography, ultrasonography, and amniotic fluid analysis.
Core GestationalTemporalContext A named gestational time period, or a gestational age.
Core GestationalTimePeriod A time relative to a pregnancy or childbirth event.
Core HumanName A name used by a human being, written as it would be typically expressed. May include a breakdown of the various elements of the name (family name, given name, etc.).
Core Identifier A unique string that identifies a specific person or thing.
Core Location A position, site, or point in space where something can be found.
Core LowerBound The lower limit on a range
Core NumberOfRepeats How many times the action should be repeated.
Core OccurrenceTimeOrPeriod The point in time or span of time in which something happens.
Core OnBehalfOf The party represented by the actual participant.
Core Priority An indication of the importance of an action.
Core QualitativeDateTime A point in time, described qualitatively.
Core Range An interval defined by a quantitative upper and/or lower bound. One of the two bounds must be specified, and the lower bound must be less than the upper bound. When Quantities are specified, the units of measure must be the same.
Core Reason The justification for an action or non-action, conclusion, opinion, etc.
Core RecurrenceRange The start and end of the overall recurrence pattern in terms of dates/times or in terms of number of repeats. Could also be an event, such as when all doses are taken.
Core Setting Description of the place or type of surroundings where something is positioned or where an event takes place.
Core State Sub-unit of a country with limited sovereignty in a federally organized country. A code may be used if codes are in common use (i.e. US 2 letter state codes). (Source: HL7 FHIR).
Core StatisticType The type of statistic that is represented by the value.
Core TimePeriod A period of time defined by a start and end time, date, or year. If the start element is missing, the start of the period is not known. If the end element is missing, it means that the period is ongoing, or the start may be in the past, and the end date in the future, which means that period is expected/planned to end at the specified time. The end value includes any matching date/time. For example, the period 2011-05-23 to 2011-05-27 includes all the times from the start of the 23rd May through to the end of the 27th of May.
Core Title A distinguishing word or group of words naming an item.
Core TypeAsaCoding
Core UpperBound The upper limit on a quantitative value.
Device Device A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Device Implanted Whether this device is implanted in the body.
Encounter PaymentSource The source of payment for the current encounter.
Encounter ReferralDate The date when the provider received a referral for service. A referral includes an oral, written, faxed or electronic request for services made by the client or on the client's behalf.
Encounter ReferralSourceType The type of person or entity that instigated the encounter.
Encounter ServiceGiven Indicates a medical service provided.
Encounter ServiceProvider The organization that provided the services rendered during this encounter.
Encounter TreatmentCooperation Whether the patient is undergoing treatment voluntarily, or under a legal order.
Entity AccessTime Point in time when data was accessed.
Entity ActiveFlag If the ActiveFlag is false, it indicates the record or item is no longer to be used and should generally be hidden for the user in the UI.
Entity ActiveFlagAsaCodeableConcept If the ActiveFlag is false, it indicates the record or item is no longer to be used and should generally be hidden for the user in the UI.
Entity Additive Additive associated with container.
Entity AdministrativeGender A gender classification used for administrative purposes. Administrative gender is not necessarily the same as a biological description or a gender identity. This attribute does not include terms related to clinical gender.
Entity AnonymizedFlag Flag indicating if personally identifiable information has been withheld or disguised.
Entity BodySite A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
Entity BodySiteMarker A marker surgically placed at the site, often during a biopsy procedure, to pinpoint the location. The marker is typically a metal clip or radioactive seed.
Entity Capacity Container volume or size.
Entity CountryOfIssue A country acting as an assuing authority for a document.
Entity DateOfBirth A date of birth or approximate year or period (year or date range), if estimated.
Entity DriversLicenseNumber Identifying information from a drivers license.
Entity ExpirationDate When the medication will expire.
Entity ExternalHealthRecord A health record other than the current health record; may have been used to help populate the current record.
Entity Facility Services and space and equipment provided for a particular purpose; a building or place that provides a particular service or is used for a particular industry. Could be a clinical site, community site, or a mobile facility.
Entity FathersName The name of the father as it was or likely to have been recorded on the birth certificate of the subject; most likely the name of the father at the time of birth of the subject.
Entity FictionalPersonFlag Flag indicating if this record represents a fictional (synthetic, not real) person.
Entity Group A set of entities (personnel, material, or places) to be considered together. May be a pool of like-type resources, a team, or combination of personnel, material and places.
Entity HandlingRisk Cautions on the handling of this specimen.
Entity Headshot A photograph showing a person's face.
Entity LanguageQualifier Additional information about a person's use of language.
Entity LanguageUsed Language used for communication by a human, either the subject of record, parent, or other involved person.
Entity LotNumber A distinctive alpha-numeric identification code assigned by the manufacturer or distributor to a specific quantity of manufactured material or product within a batch.
Entity Manufacturer The organization producing the product or test.
Entity MedicationOrCode A medication entity or a medication code.
Entity MobileFacility A facility that moves from place to place, such as Meals-On-Wheels.
Entity Organization A social or legal structure formed by human beings.
Entity PartOf The larger entity that this is a portion of.
Entity Party A person, organization, or object that be involved in a healthcare activity. A party has a separate and distinct existence, and objective or conceptual reality. Includes information, physical objects, and roles.
Entity PassportNumber Credential indicating citizenship.
Entity Patient A person in the role of a patient, including extended demographic information about the subject of this health record.
Entity RelatedPerson A person in a role defined in relationship to a patient
Entity Role Abstract parent class for human parties, such as practitioners, patients, research subjects, and related persons. Role can also represent an object playing a specific role, such as a room playing the role of operating theater. The value contains the entity (party) playing the role.
Entity SequenceNumber The sequence number for this specimen in a collection of specimens.
Entity SocialSecurityNumber A US social security number (SSN).
Entity SpecialHandling Information about the proper handling of the specimen.
Entity Specimen Sample for analysis
Entity SpecimenQuantity Quantity of specimen within container.
Entity SpecimenTreatment Treatment performed on the specimen.
Entity SpokenLanguageProficiency Accuracy and fluency in spoken communication in a language.
Entity StateOfIssue A state or country acting as an assuing authority for a document.
Entity Type The most specific code (lowest level term) describing the kind or sort of thing being represented.
Entity WrittenLanguageProficiency Accuracy and fluency of reading and writing in a language.
Finding ApplicableAgeRange The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so.
Finding ApplicableSubpopulation Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race.
Finding ChangeFlag Indicator of significant change (delta) from the last or previous measurement.
Finding Evidence A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
Finding Finding Base class for all kinds of determinations: questions/answers, conditions, observations, allergies, and other findings. The subject of a finding can be the entire patient, or an entity such as a location body structure, intervention, or condition. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments.
Finding FindingMethod The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Finding FindingStatus Indicates whether the finding is preliminary, amended, final, etc..
Finding FocalSubject For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Finding FocalSubjectReference For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Finding Interpretation A clinical interpretation of a finding.
Finding NegationFlag A flag that indicates the meaning to be conveyed is the logical opposite of the current assertion. The assertion is negated only when the NegationIndicator is true. If absent or false, the assertion is not negated.
Finding ObservationCode A code that represents what the finding concerns, for example, the subject's height, blood pressure, disease status, wound dimensions, diabetes risk, etc. Although named ObservationCode, in different contexts the same attribute might be more naturally referred to as a property, observable, or test code. In assertions (observations without an explicit question), the observation code is defaulted to a value representing 'assertion'.
Finding ObservationQualifier A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
Finding ReferenceRange The usual or acceptable range for a test result.
Finding ValueAbsentReason Provides a reason why the value of the observation is missing, if it is expected (some observations are not expected to have a value).
Immunization Vaccine A specific type or manufactured instance of a vaccine, a prophylactic or therapeutic preparation given to produce immune response to pathogenic organisms or substances.
Medication Dosage The dosage of the medication, prescribed or taken.
Medication DoseAmount The amount of medication taken per dose, as a quantity or range.
Medication MedicationAfterChange The medication taken, prior to the change.
Medication MedicationBeforeChange The medication taken, prior to the change.
Medication MedicationChange Description of a modification or change of a medication or dosage.
Medication NumberOfRefillsAllowed The maximum number of times the dispense can be repeated. For medication dispense, this integer does NOT include the original order dispense. This means that if an order indicates dispense 30 tablets plus 3 repeats, then the order can be dispensed a total of 4 times and the patient can receive a total of 120 tablets.
Medication QuantityPerDispense The amount that is to be dispensed for one fill.
Medication RouteIntoBody The way a substance enters an organism after contact, particularly, the route of drug administration.
Medication SupplyDuration Identifies the period time over which the supplied product is expected to be used, or the length of time the dispense is expected to last.
Oncology StagingTiming Indicates when the staging was done, in terms of treatment landmarks, for example, at diagnosis (clinical), at surgery(pathologic), after treatment (post-neoadjuvant), at entry to a clinical trial, or at recurrence.
Procedure Access The route used to access the site of a procedure. It is used to distinguish open, closed, and percutaneous procedures.
Procedure AmountOrSize The quantity of specimen collected
Procedure AssociatedStudy The clinical trial or other formal study related to this procedure.
Procedure DirectSite The site where the procedure is performed.
Procedure DirectSiteCode The site where the procedure is performed.
Procedure ImagingSubstance Substance used for this imaging procedure such as a contrast agent.
Procedure IndirectDevice An indirect device used for this procedure.
Procedure IndirectDeviceCode An indirect device used for this procedure.
Procedure IndirectSite The indirect site for this procedure.
Procedure IndirectSiteCode The indirect site for this procedure.
Procedure SurgicalApproach The technique used to reach the site of the procedure. Approaches may be through the skin or mucous membrane, through an orifice or external.
Procedure UsingAccessDevice The access device used to perform the procedure.
Procedure UsingAccessDeviceCode The access device used to perform the procedure.
Procedure UsingDevice The device used to perform the procedure.
Procedure UsingDeviceCode The device used to perform the procedure.
Research TerminationReason A description and/or code explaining the premature termination of the study.
Skin SupportSurfaceBodyPosition What body positions the surface can be used for, specifically, sitting or lying.
Skin SupportSurfaceCategory The category of support surface.
Skin SupportSurfaceComponent A physical material, structure, or system used alone or in combination with other components to fashion a support surface.
Vital HeadTiltAngle The angle at which the head is tilted relative to a level position while physiologic tests are taken.