Standard Health Record

Extensions defined as part of this Implementation Guide

Name Definition
AbsenceContext

Indicates the finding in question is either known absent (ruled out), not suspected, or unknown.

AccessTime

Point in time when data was accessed.

ActionRequestedStatement

Abstract class representing a request for any type of action.

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.

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.

Additive

Additive associated with container.

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).

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.

AdverseEventTopic

The topic (independent of context) for any unfavorable and unintended sign, symptom, disease, or other medical occurrence with a temporal association with the use of a medical product, procedure or other therapy, or in conjunction with a research study, regardless of causal relationship. EXAMPLE(S): back pain, headache, pulmonary embolism, death. An AdverseEvent may also document a causal relationship to an intervention is at least a reasonable possibility i.e., the relationship cannot be ruled out.

AnatomicalLocation

A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.

Annotation

An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.

AnonymizedFlag

Flag indicating if personally identifiable information has been withheld or disguised.

AssociatedStudy

The related clinical trial or other formal study.

Attribution

Information ascribing the record to a particular contributor or responsible person.

BodyStructureTopic

Presence (or absence) of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds.

Capacity

Container volume or size.

Category

A class or division of people or things having particular shared characteristics

ClinicalNote

An entry concerning a patient where the result is a narrative text. Can be related to a specific Focus, such as a condition; and evidence and interpretation from FindingTopic.

ClinicalStatement

A special type of information entry consisting of a topic and a context. The ClinicalStatement class provides the core pattern for more specific clinical statement classes, such as a statement that a finding has been found in a patient or that a procedure has been proposed by a clinical decision support system. The ClinicalStatement pattern defines the core attributes common to most clinical statements and specifies a composition pattern that encourage model component reuse and better alignment with the SNOMED CT Concept Model. A clinical statement is composed of the StatementTopic class (grouping of attributes for capturing information about a procedure or a clinical finding) and the StatementContext class (grouping of attributes providing the context for the statement topic such as whether a procedure was performed, requested, not performed or whether a finding is suspected present or absent in the patient). At the archetype level, the topic and context components are coordinated to form the clinical statement. For instance, the composition of the ProcedureTopic with the NotPerformed context indicates that the given procedure was not performed.

ClockDirection

A direction indicated by an angle relative to 12 o’clock.

CodeableConcept

A set of codes drawn from different coding systems, representing the same concept.

CollectionMethod

How the specimen was obtained.

CollectionSite

The body site where specimen was collected

CollectionTime

When the sample was obtained, as a specific time or time period.

ConditionTopic

A condition, independent of context. ‘Condition’ is interpreted broadly to include disorder, abnormality, problem, injury, complaint, functionality, concern, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble, independent of context. CIMI deviation: AnatomicalLocation is included here, rather than being a property of FindingSiteAssertionTopic, since it is a common property of conditions. Severity, diseasePhase, periodicity, and other properites of an actual observed condition belong in ConditionPresenceContext.

ContactPoint

An electronic means of contacting an organization or individual.

ContextCode

A code representing the ontological status of the statement, e.g., whether it exists, does not exist, is planned, etc. Attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) Concept Model context attributes: ‘Finding context (attribute)’ (SCTID: 408729009) and ‘Procedure context (attribute)’ (SCTID: 408730004). The range allowed for this attribute shall be consistent with the SNOMED CT concept model specification for SWEC.

Cosigned

Provenance information specific to the cosigning of the clinical statement.

Country

Country - a nation as commonly understood or generally accepted, expressed in ISO 3166 Alpha-2 (2-letter) codes.

CountryOfIssue

A country acting as an assuing authority for a document.

CreationTime

The point in time when the information was recorded in the system of record.

DateOfBirth

A date of birth or approximate year or period (year or date range), if estimated.

DerivedFrom

Indicates the source of information in the case the Entry has been created by logical extension or modification of one or more source entries.

Details

An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.

Diagnosis

A diagnosis, which is a disease or injury determined to be present through evaluation of patient history, examination, and/or review of laboratory data.

DiagnosticService

A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.

DistanceFromBreastSiteToNipple

Distance between the feature of interest (e.g., the tumor) and the nipple.

Dosage

The dosage of the medication, prescribed or taken.

DriversLicenseNumber

Identifying information from a drivers license.

EffectiveTimePeriod

The date and time span for which something is active, valid, or in force.

Employer

A person or organization that hires the services of another.

EncounterClass

Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations.

Encounter

A description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

EntityOrRole

Parent class entity and role.

ExternalHealthRecord

A health record other than the current health record; may have been used to help populate the current record.

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.

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.

FictionalPersonFlag

Flag indicating if this record represents a fictional (synthetic, not real) person.

FindingMethod

The technique used to create the finding; for example, the specific imaging technique, lab test code, or assessment vehicle.

CIMI Alignment: In CIMI V0.0.4, this attribute was called ‘method’. The value set binding reflects CIMI’s preference for LOINC codes.

FindingStatus

Indicates whether the finding is preliminary, amended, final, etc.

FindingTopic

Base class - independent of context - 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.

CIMI Alignment: In CIMI V0.0.4, FindingTopic has four attributes: result, description, multimedia, and intepretation. The model assumes the result of the finding, and interpretationof that result, are not part of the topic (the question), but part of the result (the answer), and therefore appears in the context (RecordedContext and PresenceContext).

HandlingRisk

Cautions on the handling of this specimen.

Headshot

A photograph showing a person’s face.

HumanName

The CIMI person name, constrained to map correctly to FHIR.

Identifier

A unique string that identifies a specific person or thing.

Independent

Base class for classes in CIMI that include enough context to stand alone. Analogous to FHIR’s DomainResource.

Interpretation

A clinical interpretation of a finding.

Language

A human language, spoken or written.

LanguageQualifier

Additional information about a person’s use of language.

LanguageUsed

Language used for communication by a human, either the subject of record, parent, or other involved person.

MedicationAfterChange

The medication taken, prior to the change.

MedicationBeforeChange

The medication taken, prior to the change.

MedicationChangeTopic

undefined

MedicationDispenseTopic

The action of ordering and deliving a medication to the party responsible for administering the medication.

Medication

A type of prescription drug or over-the-counter drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition, but excluding vaccines.

MedicationNonAdherenceReason

Reason that patient did not adhere to a medication regimen.

Method

The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.

MobileFacility

A facility that moves from place to place, such as Meals-On-Wheels.

MorphologyBehavior

A description of the morphology and behavioral characteristics of the cancer.

Morphology

The kind of structure being represented. This can define both normal and abnormal morphologies.

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.

NumberOfRepeats

How many times the action should be repeated.

OccurrenceTimeOrPeriod

The point in time or span of time in which something happens.

OnBehalfOf

The party represented by the actual participant.

Outcome

The result of performing an action or behavior, for example, an adverse reaction or new finding.

PartOf

The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.

Participant

An entity (usually a Practitioner, Patient, or Organization but potentially a device or other entity) that participates in a healthcare task or activity.

ParticipationPeriod

The point in time or span of time the participant is involved.

ParticipationType

The role played by the participant engaged in the action, for example, as the attending physician, surgical assistant, etc.

PassportNumber

Credential indicating citizenship.

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.

PersonOfRecord

The person this entry belongs to.

PreferredFlag

Code indicating the preference associated with the use of this name.

PriorityRank

An indication of the importance of an action.

ProgressionEvidence

The type of evidence considered in determining disease progression.

QuantityPerDispense

The amount that is to be dispensed for one fill.

Reason

The justification for an action or non-action, conclusion, opinion, etc.

RecordStatus

Concept indicating the state of this record, e.g., ‘entered in error’.

RecordedContext

Context for recording a finding, usually a Panel, used to indicate an evaluation has been made.

For example, measurement of blood pressure that has been made simply exists (although the value can be present or absent, accurate or inaccurate). The RecordedContext indicates the information presented stands on its own as presented. It can also apply to clinical notes.

Recorded

The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.

RecordedOn

The time of the attribution action.

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.

RelatedRequest

The proposal, order, or plan that is partly or wholly fulfilled by the performance of this act.

RelationshipToPersonOfRecord

The relationship of the SubjectOfInformation to the subject of record.

RelevantTime

The time or time period that the finding addresses.

The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).

RequestedAgainstContext

Represents a recommendation or order from a practitioner or clinical decision support system to NOT perform an act.

SequenceNumber

The sequence number for this specimen in a collection of specimens.

ShrId

A unique, persistent, permanent identifier for the overall health record belonging to the PersonOfRecord.

Signature

A digital Signature - XML DigSig, JWT, Graphical image of signature, etc.

Signed

Provenance information specific to the signing of the clinical statement.

SocialSecurityNumber

A US social security number (SSN).

SourceOfInformation

The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.

SpecialHandling

Information about the proper handling of the specimen.

SpecimenQuantity

Quantity of specimen within container.

SpecimenTreatment

Treatment performed on the specimen.

SpokenLanguageProficiency

Accuracy and fluency in spoken communication in a language.

StageTimingPrefix

Indicates when the staging was done, in terms of treatment landmarks.

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).

StateOfIssue

A state or country acting as an assuing authority for a document.

StatementContext

Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of ‘absent’, then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.

StatementTopic

Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement.

StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc…), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).

StatisticType

The type of statistic that is represented by the value.

Status

The current standing or state.

SubjectOfInformation

The person or thing that this entry relates to, usually the Person of Record (see Entry). 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, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation – unlike CIMI. There’s no action to participate in. Participant has extra unnecessary attributes, such as ‘onBehalfOf’.

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.

TerminationReason

A description and/or code explaining the premature termination of the study.

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.

TopicCode

The concept representing the finding or action that is the topic of the statement.

For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the ‘question’ or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.

Type

The most specific code (lowest level term) describing the kind or sort of thing being represented.

Verified

Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

WrittenLanguageProficiency

Accuracy and fluency of reading and writing in a language.

code

The code that represents the value of the SHR element to which it is applied.

string

The string that represents the value of the SHR element to which it is applied.