SHR Reference Model

Standard Health Record (SHR) Reference Model Specification

Welcome to the SHR Reference Model Documentation
Element Description
Abatement
The end, remission or resolution.
AcademicProblem
A problem with learning or behavior in a learning environment.
Access
The route used to access the site of a procedure. It is used to distinguish open, closed, and percutaneous procedures.
AccessionIdentifier
Identifier assigned by the lab
AccessTime
Point in time when data was accessed.
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.
ActionContext
The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
ActionTaken
The action taken as a result of the adverse reaction. May include changing or discontinuing medication, reducing dose, etc.
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.
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.
ActualActivities
Activites carried out for this goal
AdditionalDoseInstruction
Supplemental instructions - e.g. 'with meals'.
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).
AddressLine
Part of an address that contains the house number, apartment number, street name, street direction, P.O. Box number, delivery hints, and similar address information. (Source: HL7 FHIR).
Adherence
The degree (frequency) that the stated treatment plan, prescription, or protocol was followed. A statement of the ability and cooperation of the patient in taking medicine or supplement as recommended or prescribed. This includes correct timing, dosage, and frequency.
AdministrationBodySite
The anatomic site at which medical intervention is applied.
AdministrationMethod
Technique for administering medication.
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.
AdverseEvent
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. The AdverseEvent may also document a causal relationship to an intervention is at least a reasonable possibility i.e., the relationship cannot be ruled out.
AdverseEventAttribution
A possible cause of an observed adverse event, known or theorized. There can be more than one possible cause.
AdverseEventGrade
A coded value specifying the level of injury suffered by the subject for whom the event is reported, using the CTCAE coding system.
AdverseReaction
An instance of a negative response to the allergy or intolerance.
Affiliation
Membership, association, or connection to an organization.
Age
How long something has existed in time.
AgeAtDeath
The age, age range, or age group when the cessation of life happens.
AgeGroup
Subgroups of populations based on age.
AgeRange
A quantitative range of ages. One of the two ages must be specified.
AlcoholBingeFrequency
How often have you had 6 or more Units if female, or 8 or more if male, on a single occasion in the last year?.
AlcoholUse
The subject's current or past use of alcohol.
AllergenIrritant
A substance that causes an allergic reaction or irritation.
AllergyIntolerance
A finding related to the presence or absence of an individual's risk or sensitivity to a substance or class of substances. A finding can be taken as tantamount to a representation of an allergic condition, allowing it to be tracked over time.
AllredIntensityScore
Part of the Allred scoring, based on the intensity of that staining, on a scale of 0 to 3.
AllredProportionScore
Part of Allred scoring, based on the percentage of cells that stain for a receptor, on a scale of 0 to 5.
AllredTotalScore
The total Allred score, the total of proportion and intensity scores, from 0 to 8.
Altitude
Height above sea level or above the earth's surface. Measured with with WGS84 datum.
AmountOrSize
The quantity of specimen collected
Aneusomy
Aneusomy (as defined by vendor kit used)
AnimalExposure
The type of animals or pets the subject is exposed to.
Annotation
An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
AnnualIncome
The amount of earnings made by a family unit in one year, estimated or self-reported.
AnonymizedFlag
Flag indicating if personally identifiable information has been withheld or disguised.
Any
The top level class in the hierarchy
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.
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.
Area
The extent of a 2-dimensional surface enclosed within a boundary.
AsNeededIndicator
Indicates the pre-condition under which the drug or intervention should be used.
Assertion
A unary observation, also known as an assertion, is an observation that takes the form of a single code, without an explicit question or property. Examples include reported symptoms such as 'chest pain' and facts such as 'patient bed in low position'. Assertions may be negated setting the NegationFlag to true. The ObservationCode is defaulted to 'assertion' since assertions have no explicit question. Assertions cannot have a ValueAbsentReason, because Assertions without the asserted value are meaningless.
AssociatedStudy
The clinical trial or other formal study related to this procedure.
Attachment
A file that contains audio, video, image, or similar content.
Attribution
Who the entry is attributed to, for example, the informer (information source), the recorder, the verifier, the responsible person, etc.
Author
The person or organization who created the entry and is responsible for (and may certify) the content.
AverageCEP17SignalsPerCell
Average number CEP17 signals per cell (dual probe only)
AverageHER2SignalsPerCell
Average number of HER2 signals per cell
AverageStainingIntensity
Part of the Allred scoring, based on the intensity of that staining, on a scale of 0 (Negative) to 3 (Strong).
BehavioralFinding
A statement about observable responses, actions, or activities of the subject. Can be used to assert or deny behaviors.
BinaryData
The data itself.
BirthSex
Administrative sex assigned at birth and recorded on birth certificate.
BloodPressure
The force of circulating blood on the walls of the arteries.
BodyHeight
The distance from the sole to the crown of the head.
BodyLength
The distance from the sole of the foot to the crown of the head, lying down (typically 0-2 years).
BodyMassIndex
A general indicator of the body fat an individual is carrying based upon the ratio of weight to height.
BodyPosition
The position or physical attitude of the body.
BodySite
A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
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.
BodySiteOrCode
A body site entity or a body site code.
BodyStructureAbsent
Absence of distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. The observation has a body site that allows the the structure to be located in the body. The observation identifier allows other observations of the same body structure to be related to QualitativeValueScaleVSthis observation and tracked over time.
BodyStructurePresent
Presence of a distinct anatomical or pathological morphological feature or organizational pattern, acquired or innate. Examples include tissue types, tumors, and wounds. Body structures are continuants that allow observations of the same body structure to be related to be tracked over time.
BodyTemperature
The measure of the level of heat in a human or animal.
BodyWeight
The mass or quantity of heaviness of an individual. Does not include estimates of fetal bodyweight.
Brand
If the product is branded, and if so, the brand name of a product.
BrandName
The marketing name for a brand name product
BRCA1Variant
Whether the patient has a mutation in the BRCA1 gene.
BRCA2Variant
Whether the patient has a mutation in the BRCA2 gene.
BreastCancer
Finding or diagnosis of cancer originating in the tissues of the breast, and potentially spread to other organs of the body.
BreastCancerBiomarkerPanel
Immunohistochemistry (IHC) assessment for estrogen receptor (ER) and progesterone receptor (PR) as well as IHC or in situ hybridization (ISH) determination of human epidermal growth factor receptor 2 (HER2) status
BreastCancerGeneticAnalysisPanel
The status of genes known or suspected to play a role in breast cancer risk, for example, the tumor suppressor genes, BRCA1 and BRCA2.
CanAffordChildCare
How often can the subject afford child care?
CanAffordClothing
How often can the subject afford clothing?
CanAffordDentalCare
How often can the subject afford dental care?
CanAffordFood
How often can the subject afford food?
CanAffordHousing
How often can the subject afford housing?
CanAffordMedication
How often can the subject afford medications?
CanAffordTransportation
How often can the subject afford transportation?
CanAffordUtilities
How often can the subject afford utilities?
Capacity
Container volume or size.
CarePlan
Describes how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.
CareTeam
Planned participants in the coordination and delivery of care for a patient or group.
Category
A class or division of people or things having particular shared characteristics
CauseCategory
Whether the adverse event is attributed to a treatment, course of the disease, unrelated to either, or unknown.
Cellularity
Percentage of cells in a sample that are cancerous
Certainty
The degree of confidence in a conclusion or assertion.
CertifiedBy
The agency certifying the test.
ChangeFlag
Indicator of significant change (delta) from the last or previous measurement.
Circumference
The length of such a boundary line of a figure, area, or object.
City
The name of a municipality, city, town, village or other community or delivery center. (Source: HL7 FHIR).
ClinicallyRelevantTime
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).
ClinicalStatus
A flag indicating whether the condition is active or inactive, recurring, in remission, or resolved (as of the last update of the Condition).
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.
CodeSystem
A formal terminology system.
CodeSystemVersion
The version of the vocabulary being used, if applicable.
Coding
Coding of a concept, drawn from a controlled vocabulary. Includes the vocabulary and version, if applicable. May include a display text, and a descriptor expressing the intended interpretation of the code.
Coinhabitant
A person living with the subject.
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.
Comparator
CompleteMembraneStainingPercent
Percentage of cells with uniform intense complete membrane staining.
Condition
A disorder, abnormality, problem, injury, complaint, risk, functionality, concern, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble. A ConditionPresent finding implies the existence of a condition as an entity. 'Condition' is interpreted broadly to cover states of existence - things the patient is or has.
ConditionAbsent
A finding that a condition is or was not present in the subject at a certain time, not necessarily the time the information is gathered.
CongenitalAbnormality
Any abnormality, genetic, anatomical, biochemical, evident at birth or during the neonatal period. Includes malformations, deformations, and chromosomal abnormalities.
ContactDetail
Describes an individual and how to reach them.
ContactPoint
An electronic means of contacting an organization or individual.
Content
An item that can constitute the payload of an Entry, aka an EntryElement.
ContentType
Mime type of the content, with charset etc.
ContraceptiveAction
A contraceptive for a patient, independent of context of being recommended, used, or not used.
ContraceptiveMethodFrequency
How often the contraceptive method is used by the subject.
ContraceptiveMethodReason
Reason for using a particular contraceptive.
ContraceptiveMethodRequested
The contraceptive method(s) proposed, recommended or prescribed by a provider, after counseling and assessment.
ContraceptiveMethodRequestedAgainst
The contraceptive method(s) recommended or prescribed by a provider, after counseling and assessment.
ContraceptiveMethodUsed
A method contraception used (or not) by the subject.
ContraceptiveNotUsedReason
If not using a method of contraception, why.
ContraceptivesUsed
How frequently the subject and partner uses contraceptives, and if so, what contraceptive methods used.
CorrectionFactor
A correction factor that is applied to the sampled data points before they are added to the origin.
Count
The number of items (0 or more), as an integer.
CountPerInterval
How many times the event should take place during one recurrence interval, for example, to specify 3-4 times per day, the CountPerInterval should be 3 to 4.
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.
Coverage
Health insurance coverage available (even if not used for payment for a given encounter).
CreationTime
The point in time when the information was recorded in the system of record.
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.
CurrentPregnancyStatus
Whether or not the subject is currently pregnant.
DailyLifeEvent
A quotidian landmark, such as rising, mealtime, or bedtime, when an event should take place.
DateOfBirth
A date of birth or approximate year or period (year or date range), if estimated.
DateOfDeath
The calendar date of subject's death.
DayOfWeek
A day of the week that the pattern should take place.
Deceased
An indication that the person is no longer living, given by a date, time of death, or a boolean value which, when true, indicates the person is deceased.
Definitional
An indicator that the item is a description of a thing, not a thing that actually exists. For example, a group of people between ages 30 and 40 with Type II diabetes can be defined, without existing as a set of particular people.
DegreeOfLymphaticInvolvement
Assessment of how much cancer is in a lymph node.
Denominator
The divisor of a fraction.
Depth
The extent downward or inward; the perpendicular measurement from the surface downward to determine deepness.
Details
An text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
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.
DeviceAction
A medical device or implanted device of a patient, independent of context of being recommended, used, or not used. Device use can be reported, directly observed, or inferred from clinical events associated with orders, prescriptions written, and other patient-reported information.
DeviceNotUsed
A record of a device not used by a patient, for example, no stent implanted.
DeviceUdi
Unique Device Identifier (UDI) Barcode string number for a device, assigned by the organization using the device.
DeviceUsed
A record of the use of a device by a patient.
DiastolicPressure
The blood pressure after the contraction of the heart while the chambers of the heart refill with blood, when the pressure is lowest.
DietFollowed
A type of nutritional plan followed by the subject.
DietNutritionConcern
An anxiety or worry about the diet or nutritional intake of the subject.
Dimensions
The number of sample points at each time point. If this value is greater than one, then the dimensions will be interlaced - all the sample points for a point in time will be recorded at once.
Directionality
Anatomical location or specimen further detailing directionality.
DirectSite
The site where the procedure is performed.
DirectSiteCode
The site where the procedure is performed.
DiseaseProgression
A finding related to the current trend of a disease. This concept is most often used for chronic and incurable diseases where the status and trendline of the disease is an important determinant of therapy and prognosis. The specific disorder being evaluated must be cited in the AssessmentFocus as a reference to a Condition.
DisplayText
A string meant for reading by a person, for example, accompanying a code.
Distance
The measure of space separating two objects or points.
District
The name of the administrative area at a level below that of a state but above that of a city or town. In the US, a county. Outside the US, a district or the equivalent. (Source: HL7 FHIR).
DomesticViolence
Whether the subject experiences domestic violence.
Dosage
The dosage of the medication, prescribed or taken.
DoseAmount
The amount of medication taken per dose, as a quantity or range.
DoseForm
The form in which active and/or inert ingredient(s) are physically presented.
DoseInstructionsText
The directions (signetur) on the drug prescription or dispensing record.
DriversLicenseNumber
Identifying information from a drivers license.
Duration
The length of time that something continues.
DurationRange
A range of durations.
EducationalAttainment
Educational attainment or level of education of individuals.
EffectiveDate
The date when something is to take effect.
EffectiveTimePeriod
The date and time span for which something is active, valid, or in force.
EmbeddedContent
Abstract class defining the common metadata of all types of encapsulated data, such as images.
EmotionalSafety
Whether the subject feels physically safe in the subject's home environment.
Employment
Engagement in an activity or service for profit, wages, salary, or as a service to others.
EmploymentStatus
Condition of employment including full- or part-time, temporary or permanent, and unemployment.
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, independent of the context of requested, planned, performed, etc.
EncounterNotPerformed
EncounterPerformed
EncounterRequested
Enrollment
Description of the group or groups enrolled or qualified to be enrolled in the study.
Entity
Base class for material and non-material things. A non-material thing might be a goal or information relevant to health care, such as an image, consent form, or report. A material thing can be seen and touched, such as a device.
Entry
Metadata attributes that apply to any item represented in the standard health record. An Entry may not belong exclusively to a single person's health record, but could represent an entity that surfaces in multiple records, such as organizations or practitioners. If the entry belongs to a single person's record, then the identity of the person of record must be recorded.
EntryId
A persistent, permanent identifier for an entry in a health record, unique within the scope of the health record.
EntryType
SHR data element identifier, as a URI. The EntryType array includes the entire 'based on' hierarchy to enable searching for classes of things, for example, searching for all vital signs, or all types of behavioral observations.
EstrogenReceptorStatus
Estrogen receptor alpha is the predominant estrogen receptor expressed in breast tissue and is overexpressed in around 50% of breast carcinomas. ER status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Ethnicity
Indicator of Hispanic or Latino origin.
EthnicityDetail
Additional description of ethnicity.
EventDuration
The length of the recurring event.
Evidence
A symptom, observation, or other item, for example, a radiology report, that serves as evidence for the current assessment.
ExcludeFlag
If true, exclude the subjects that match the criterion.
ExerciseHoursPerWeek
Hours of moderate or vigorous activity per week.
ExpectedMethod
The method that should be used to carry out the 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.
ExpectedPerformer
Who should carry out the tests. For example, the patient or caregiver.
ExpectedPerformerType
What type of party should carry out the testing.
ExpirationDate
When the medication will expire.
ExposureAmount
The amount of substance used or exposed to in a given period of time (e.g., 10 cigarettes per day). Can also be used to record total lifetime exposure (e.g., 80 REMS/lifetime).
ExposureMethod
How the exposure occurred, e.g. cutaneous contact, injection, ingestion, sexual contact, inhalation.
ExposureReason
Why the exposure occurred.
ExposureRoute
The way a substance enters an organism after contact, particularly, the route of drug administration.
ExposureSourceOrVector
Where the substance originated. Vectors include animals (e.g., tick, mosquito, cats, livestock) capable of transmitting an infectious agent among vertebrates. Sources could include food, contaminated drinking water, air, radon gas in the home, etc.
ExposureToAgent
Documentation of exposure to a substance, type of substance, or disease vector potentially affecting health, including blood products, farm animals or pets, recreational drugs, sexual transmitted diseases, foods, toxins, pathogens, noise, radiation, pollutants, or prenatal exposures to teratogens. Can be used to deny such exposures via the NegationFlag.
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.
FacilityName
The DBA (doing business as) or most commonly-used name for a facility.
FamilyMemberCondition
A condition of a person related to the person of record.
FamilyMemberConditionAbsent
A condition of a person related to the person of record.
FamilyName
The portion of a person's name that reflects the genealogy of the person. In western cultures, this is the 'last' name. In eastern cultures, the family name appears before the person's given name(s). In some cultures (e.g. Eritrea) the family name of a son is the first name of his father. (Source: HL7 V3).
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.
FinancialSituationPanel
Measures of the ability of the subject to obtain and pay for the necessities of life.
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.
FindingMethod
The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
FindingStatus
Indicates whether the finding is preliminary, amended, final, etc..
FocalSubject
For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
FocalSubjectReference
For use when FHIR's subject does not allow the desired type of Subject in the Finding.Subject field.
Formalism
The system of formal syntax or interpretation associated with parsable content.
Frequency
How many occurrences of an event per unit of time.
FrequencyOfUse
A description of the frequency of substance use.
GenderIdentity
Subjective personal perception of one's own gender, which can be male, female, a blend of both, or neither.
GeneralizedAge
Qualitative or quantitative, exact or inexact description of age.
GeneralizedDateTime
A point in time, specified qualitatively or quantitatively.
GeneralizedDuration
The duration of an event, qualitatively or quantitatively.
GeneralizedFrequency
The frequency of an event, qualitatively or quantitatively.
GeneralizedLikelihood
Quantitative or qualitative measure of likelihood.
GeneralizedTemporalContext
A generalized indicator of a dateTime or an age when an event happened.
GeneticVariant
Whether a subject carries a mutation in a particular gene.
GeopoliticalLocation
The countries of the world and major geopolitical subregions, such as US states.
Geoposition
The location on the surface of the Earth, described by a latitude and longitude (and optional altitude).
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.
GestationalTemporalContext
A named gestational time period, or a gestational age.
GestationalTimePeriod
A time relative to a pregnancy or childbirth event.
GivenName
A set of names given to a person at birth, but not including the family name. In western cultures, this property would contain the 'first' and 'middle' names. Note that in some cultures, the given name is placed after the family name. Also note this property contains multiple elements, so it can handle those situations where a person has more than one 'middle' name. (Source: HL7 V3).
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.
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.
HandlingRisk
Cautions on the handling of this specimen.
Hash
A hash code of the data (sha-1, base64ed)
HasSufficientFood
Frequency that the person of record unable to obtain food to stay hunger.
HeadCircumference
Circumference of the head (typically 0-2 years).
Headshot
A photograph showing a person's face.
HeadTiltAngle
The angle at which the head is tilted relative to a level position while physiologic tests are taken.
HeartRate
The number of times the heart ventricles contract per unit of time, usually per minute.
HER2byImmunohistochemistry
HER2 status as determined by Immunohistochemistry (IHC)
HER2byInSituHybridization
HER2 status as determined by In Situ HybridizationISH.
HER2ReceptorStatus
HER2 receptor status. HER2 is a member of the human epidermal growth factor receptor family of proteins and is encoded by the ERBB2 oncogene. HER2 is overexpressed in 20-30% of breast tumors,10 and is associated with an aggressive clinical course and poor prognosis. HER2 status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
HER2toCEP17Ratio
HER2 to CEP17 Ratio (dual probe only)
HeterogeneousSignals
Whether In Situ Hybridization signals were heterogeneous.
HistologicGrade
The Elston Grade/Nottingham Score, representative of the aggressive potential of the tumor. Well differentiated (Grade 1) look similar to normal cells and are usually slow growing, while poorly differentiated cells (Grade 3) look very different than normal and are fast-growing.
HIVScreeningTestPerformed
The performance of a HIV Screening Test. Results will be in an accompanying observation.
HIVScreeningTestRequested
A request for a rapid HIV screening test.
HIVSupplementalTestPerformed
The performance of supplement HIV test, following up an initial screening. Results are in the form of an observation.
HIVSupplementalTestRequested
A request for a confirmatory or additional test for HIV infection.
HomeEnvironmentRisk
A risk experienced in the home environment.
HoursSleepPerNight
Typical hours spent sleeping per night.
HouseholdSituationPanel
Information about the makeup of the household of the subject.
HouseholdSize
The number of people living together with mutual financial dependency. Besides the subject, the household size may include spouse or partner, dependent children including adopted and foster children, dependent parents, dependent siblings and other relatives, but not roommates, ex-spouses, non-dependent children, and unborn children. If the subject lives alone, the household size is 1.
HousingSecurity
Whether the subject is at-risk of losing their housing or in a stable housing situation.
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.).
HumanNamePrefix
Contains a set of honorific terms that typically appear before a person's name, for example Mr., Mrs., Dr., etc. Prefixes have a strong association to the immediately following name part. (Source: HL7 V3).
HumanNameSuffix
Part of the name that is acquired as a title due to academic, legal, employment or nobility status, etc. and that appears at the end of the name.
Identifier
A unique string that identifies a specific person or thing.
ImagingAction
Experimental class for an imaging procedure. This class is still incomplete at this time.
ImagingProcedurePerformed
ImagingProcedureRequested
ImagingSubstance
Substance used for this imaging procedure such as a contrast agent.
ImmersionDepth
Depth of penetration (sinking) into a support surface.
ImmunizationAction
Describes the event of a patient being administered a vaccination or a record of a vaccination as reported by a patient, a clinician or another party and may include vaccine reaction information and what vaccination protocol was followed.
ImmunizationGiven
A vaccination that was administered to the subject.
ImmunizationNotGiven
An immunization that was not given to the subject.
ImmunizationRequested
An immunization that is proposed or planned for the subject.
ImmunizationRequestedAgainst
An immunization that is specifically not recommended, perhaps contraindicated for the individual.
Implanted
Whether this device is implanted in the body.
IncomeSource
Where the household income comes from.
IncomeStability
Whether the subject regards his or her source of income as dependable.
IndirectDevice
An indirect device used for this procedure.
IndirectDeviceCode
An indirect device used for this procedure.
IndirectSite
The indirect site for this procedure.
IndirectSiteCode
The indirect site for this procedure.
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.
Ingredient
Specifies an material component in a non-medication substance.
IngredientAmount
The amount of an ingredient in a mixture, as a ratio. For example, 250 mg per tablet is expressed as a ratio where the numerator is 250mg and the denominator is 1 tablet.
Injury
Damage inflicted on the body by an external force.
InsuranceMemberId
Patient identifier at a healthcare provider, insurer, or other related organization.
IntegerQuantity
A Quantity that is an integer.
IntercourseDifficulty
Condition affecting sexual intercourse.
Interpretation
A clinical interpretation of a finding.
IntravenousDrugUse
Records whether the subject injects recreational drugs.
IsActiveIngredient
True if the ingredient is an active ingredient in the medication.
Issuer
An organization who issues a qualification, identifier, or license.
Jurisdiction
The country, state or other region taking legal responsibility for the conduct of the study.
Ki-67LabelingIndex
Ki-67 is a protein phosphatase whose expression is strongly associated with cell proliferation and encoded by the MKI67 gene. The Ki67 labeling index is the fraction of Ki-67-positive cells to total cells in a tumor specimen and may be useful for determining prognosis with respect to survival and disease recurrence. The more positive cells there are, the more quickly they are dividing and forming new cells. ReferenceRange: Low <10, Intermediate 10-20, >20 High
LaboratoryProcedure
A procedure performed on a collected specimen such as a blood panel or a biopsy.
LaboratoryProcedurePerformed
LaboratoryProcedureRequested
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.
LargestLymphNodeSize
The largest dimension of the largest lymph node invaded by cancer cells.
LastUpdated
The most recent date the entry was changed.
Laterality
Anatomical location or specimen further detailing the side(s) of interest.
Latitude
The angular distance north or south between an imaginary line around a heavenly body parallel to its equator and the equator itself. Measured with with WGS84 datum.
Length
The measurement or linear extent of something from end to end; the greatest dimensions of a body.
LifeEventOffset
A time in minutes before or after a given life event, for example, 30 minutes before a meal. Whether this means before or after is carried by the life event code.
Likelihood
A measure of the expectation of the occurrence of a particular event, as a percentage.
Location
A position, site, or point in space where something can be found.
Longitude
An imaginary great circle on the surface of a heavenly body passing through the poles at right angles to the equator. Measured with with WGS84 datum.
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.
LowerBound
The lower limit on a range
LowerLimit
The lower limit of detection of the measured points. This is needed if any of the data points have the value 'L' (lower than detection limit).
LymphaticInvolvement
Description of lymph nodes contain cancer cells.
M-Stage
Part of the TNM classification system representing metastases. The system is used to describe the spread of cancer to other parts of the body. See Table 144 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm
ManagingOrganization
The organization that manages the operation of an activity, facility, or service provision.
Manifestation
A sign or symptom of an underlying condition.
Manufacturer
The organization producing the product or test.
MaritalStatus
The most recent marital status of a person.
MaxCount
Upper bound on a count.
MaximumDosePerTimePeriod
The maximum amount of a medication to be taken in a given period of time (e.g., no more than x in any 24-hour period)
MedicalInterpreterNeeded
Whether the subject requires an interpreter to communicate with an English-speaking provider.
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.
MedicationAction
A course or dose of medication for a patient, independent of context of being recommended, used, or not used. Medication use can be reported, directly observed, or inferred from clinical events associated with orders, prescriptions written, pharmacy dispensings, procedural administrations, and other patient-reported information.
MedicationAfterChange
The medication taken, prior to the change.
MedicationBeforeChange
The medication taken, prior to the change.
MedicationChange
Description of a modification or change of a medication or dosage.
MedicationDispenseAction
The action of ordering and deliving a medication to the party responsible for administering the medication.
MedicationDispensed
Indicates that a medication product has been dispensed for a named person/patient. This includes a description of the medication product (supply) provided and the instructions for administering the medication. The medication dispense is the result of a pharmacy system responding to a medication order.
MedicationIngredient
Specifies an material component in a medication.
MedicationNotDispensed
Indicates that a medication product has NOT been dispensed for a named person/patient. This may be a result of the timing out of an order or detection of pharmacist of duplicate prescription or other reason.
MedicationNotRequested
A record of a medication NOT prescribed. Recorded only when deviating from the normal expectation, care plan, or standard of care.
MedicationNotUsed
A record of a medication NOT used. Although usually not required, a medication not used is sometimes reported when deviating from normal expectation or care plan.
MedicationOrCode
A medication entity or a medication code.
MedicationRequested
An order for a medication to be dispensed and instructions for use.
MedicationUsed
A record of the use of a medication.
Member
A person or entity in a group.
Members
Members represent the elements of a group of a related but independent observations. Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent observation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself.
MembershipCriterion
An inclusion or exclusion criterion as part of defining a cohort. If the criterion is an unary, then ObservationCode must be SCT#385432009 (not applicable)
MentalHealthCondition
A condition relating to a person’s psychological and emotional well-being.
Method
The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
MilitaryBranch
The branch of the US military that the subject has served.
MilitaryService
History of service in the US military.
MilitaryServiceDischargeStatus
How the subject was formally discharged from the US Military.
MilitaryServiceEra
The time period of US military service.
MilitaryStatus
The current connection to the US military.
MillisecondsBetweenSamples
The length of time between sampling times, measured in milliseconds.
MinCount
Lower bound on a count.
MitoticCountScore
How fast the tumor cells are growing and dividing, determined from the number of mitotic cells present. Scored 1 to 3, with 3 being the most mitotic cells.
MobileFacility
A facility that moves from place to place, such as Meals-On-Wheels.
Money
Representation of an amount of currency or monetary value.
Morphology
The kind of structure being represented. This can define both normal and abnormal morphologies.
MostRecentOccurrenceTime
The time of the last or latest of a series of events.
MothersMaidenName
The name of the mother as it was or likely to have been recorded on the birth certificate of the subject. This is most likely the name prior to marriage of the mother (aka the maiden name).
MultipleBirth
Indication if the person was part of a multiple birth event.
MultipleBirthOrder
Order of birth of the person in multiple birth event (if part of multiple birth).
N-Stage
The presence of metastases in regional lymph nodes. TNM node category for staging derived from the American Joint Committee on Cancer. See Table 147 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm
Narrative
A human-readable narrative, potentially including images, that contains a summary of the resource, and may be used to represent the content of the resource to a human.
NarrativeQualifier
Additional information on how the narrative was generated, and the scope of information contained.
NationalProviderIdentifier
A unique 10-digit number to allow US healthcare providers to identify themselves in a standard way throughout the healthcare industry.
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.
NicotineUse
The subject's current or past use of nicotine.
NoAdverseEvent
Documentation of a situation where no adverse event has been detected or is known.
NoAllergyToSubstance
Used to record that a particular substance or class of substances does not pose a known elevated risk to the subject. NoAllergyToSubstance is not an assertion because the value (a code representing a substance) does not carry the complete meaning.
NoKnownAllergy
Express no known allergies to broad classes: anything, animals, drugs, foods, or environmental factors. NoKnownAllergy is an assertion because the code, such as 'No known food allergy' carries the complete meaning.
NonCashBenefit
Government benefits received by the focal subject, other than cash benefits.
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.
NuclearPleomorphismScore
How large and varied the nuclei of the tumor cells are. Scored 1 to 3, with 3 being the most pleomorphism.
NuclearPositivity
The percentage of cells that test (stain) positive for the presence of a receptor.
NumberOfDependents
The number of dependents supported by the subject.
NumberOfLivingChildren
Number of living children.
NumberOfLymphNodesInvolved
A count of lymph nodes invaded by cancer cells of those examined.
NumberOfPreviousPregnancies
Number of previous pregnancies.
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.
NumberOfSexualPartnersPastYear
Number of sexual partners in past year.
Numerator
The dividend of a fraction.
Objective
Describes the of an expected or desired achievement that is well-defined, specific, measurable, and derived from one or more goals. The context is inherited from the context of the parent goal, i.e., if the goal is #proposed, then the objective is also #proposed
Observation
Base class for observations (measurements, tests, or questions) and a value containing the result (answer). 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.
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'.
ObservationComponent
A simplified, non-separable observation consisting of a observation code, value (or value absent reason), reference range, and interpretation. The subject of the observation component is the same as in the parent observation.
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.
Occupation
The principal activity that a person does to earn money, specifying the job performed by the subject, for example, accountant, programmer analyst, patient care associate, staff nurse, etc.
OccurrenceDuration
The length of time in which something happens.
OccurrencePeriod
The point in time or span of time in which something happens.
OccurrenceTime
The point in time in which something happens.
OccurrenceTimeOrPeriod
The point in time or span of time in which something happens.
OnBehalfOf
The party represented by the actual participant.
ONCSmokingStatus
Records the extent of the subject's use of tobacco.
Onset
The beginning or first appearance of a mental or physical disorder.
Organization
A social or legal structure formed by human beings.
OrganizationAlias
A list of alternate names that the organization is known as, or was known as in the past.
OrganizationalIdentifier
A code identifying a specific organization. The NPI should be provided, if available. Other business identifiers, such employer tax ID, or MVX code for vaccine manufacturers, should also be provided.
OrganizationIdentifier
An identifier of the organization. An NPI preferred, tax id is allowed, and a local id is allowed in addition to ‘authoritative’ identifier
OrganizationName
The name of the organization.
Origin
The base quantity that a measured value of zero represents. In addition, this provides the units of the entire measurement series.
OtherReceptorScoringSystem
A scoring system other than Allred.
Outcome
The result of performing an action or behavior, for example, an adverse reaction or new finding.
OverTheCounter
True if the medication is available to consumers without a prescription.
OxygenSaturation
Oxygen saturation in Arterial blood by Pulse oximetry.
Package
The kind of container the medication comes in.
ParsableContent
A string that follows a formal syntax and can be analyzed and broken into meaningful parts.
Participant
An object (usually a Person, Party, or Organization but potentially a device or other Entity) that participates in a 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.
PartOf
The larger entity that this is a portion of.
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.
PassportNumber
Credential indicating citizenship.
Patient
A person in the role of a patient, including extended demographic information about the subject of this health record.
PatientInstructions
Information for the patient, such as, where to get the test, how to prepare for the test, etc.
PaymentSource
The source of payment for the current encounter.
Percentage
A percentage value where 100.0 represents 100%.
PercentageAmplified
Percentage of cells with amplified HER2 signals
PercentageInSituCarcinoma
The percentage of the cancer that is in situ, as opposed to invading other tissues.
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.
PerformerInstructions
Information for the performer of the test, if needed.
Person
A person relevant to the health or social situation of the subject (including the person of record him or herself).
PersonOfRecord
The person this record belongs to.
PhysicalActivityLevel
The amount of exercise or other physical activity compared to others of the same age. See BMC Medical Research Methodology 2012 12:20 1471-2288.
PhysicalActivityLimitation
Anything that limits physical activity, including health factors, logistical, monetary, or social restrictions.
PhysicalActivityPanel
Questions related to physical activity.
PhysicalSafety
How often the subject feels physically safe in the subject's home environment.
PlaceOfBirth
The location of a birth event. There may be multiple entries, but a person has only one place of birth.
PlainText
A text written in a human language.
PlannedActivities
Activites planned for this goal
PortionTotality
Further detail of the anatomical location or specimen detailing whether it includes the entire entity or only a part or portion.
PostalCode
A sequence of letters and digits used as part of a postal address, often designating a geographic region
Practitioner
A person who practices a healing art.
Preexisting
If the problem or condition existed before the current episode of care.
PregnancyHistory
Information about current and past pregnancies.
PregnancyIntention
Whether the subject or his/her partner has a plan or desire to either become pregnant or have a child in the next year/near future.
PrenatalExposure
Fetal contact with a dangerous substance via the mother.
PrimaryAntibody
PrincipalInvestigator
Indicates the individual who has primary oversite of the execution of the study.
Priority
An indication of the importance of an action.
ProcedureAction
Description of a healthcare procedure, independent of action context. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.
ProcedureNotPerformed
ProcedurePerformed
ProcedureRequested
ProcedureRequestedAgainst
ProgesteroneReceptorStatus
Progesterone receptor is expressed in 65% of breast carcinomas. PR status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.
Purpose
Describes how the item is (or was) used or applied.
Qount
The whole number of items, as a unit-bearing quantity.
Qualification
A right to practice medicine obtained by training and certification.
QualitativeDateTime
A point in time, described qualitatively.
QualitativeFrequency
The frequency of an event, described qualitatively.
QualitativeLikelihood
A qualitative (subjective) likelihood.
Quantity
A quantity with units, whose value may be bounded from above or below, as defined in FHIR
QuantityPerDispense
The amount that is to be dispensed for one fill.
QuestionAnswer
A simplified observation consisting of a question-answer pair. The question is identified by the ObservationCode, and the answer (if given) is in Value. If the answer is missing, the ValueAbsentReason must be provided.
Race
Subjective association of a person with a named category of humans sharing common history, traits, place of family origin, nationality, tribe, or other inherited background.
RaceDetail
Additional description of race or heritage.
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.
Ratio
A unit of measurement for the quotient of the amount of one entity to another.
ReadinessToChange
How motivated the subject is to change the behavior, if the behavior is ongoing, and change would be beneficial.
Reason
The justification for an action or non-action, conclusion, opinion, etc.
ReasonForBehavior
Why the behavior has taken or is taking place.
ReceivedTime
Time received by accepting facility or unit.
RecurrenceInterval
The period of time after which the pattern repeats, for example, each day. To specify an event should take place every other Monday, the recurrence interval should be two weeks, and DayOfWeek should be Monday.
RecurrencePattern
A set of rules that describe when a recurring event is scheduled.
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.
ReferenceRange
The usual or acceptable range for a test result.
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.
ReferralSourceType
The type of person or entity that instigated the encounter.
Refseq
The Reference Sequence (RefSeq) collection provides a comprehensive, integrated, non-redundant, well-annotated set of sequences, including genomic DNA, transcripts, and proteins. RefSeq sequences form a foundation for medical, functional, and diversity studies. They provide a stable reference for genome annotation, gene identification and characterization, mutation and polymorphism analysis (especially RefSeqGene records), expression studies, and comparative analyses.
RelatedEncounter
If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
RelatedFinding
Findings associated with this item.
RelatedPerson
A person in a role defined in relationship to a patient
RelatedPlan
The plan that this action fulfills
RelatedRequest
The request that this action fulfills
RelationshipType
The relationship of the subject to another person in the same extended family or extended family. May or may not be a blood relative.
Religion
The affiliation of the person with a recognized religious group.
ReligiousCongregation
A group of place of religious practice.
ReligiousPracticeStatus
The extent to which the religious practice is actively followed.
ReligiousRestriction
Any restriction on that derives from religion and may impact medical treatment, other than dietary (handled elsewhere).
RequestedAgainstContext
Represents a recommendation or order from a practitioner or clinical decision support system to NOT perform an act.
RequestedContext
An order for something to take place.
RequestIntent
Indicates the level of authority/intentionality associated with the request and where the request fits into the workflow chain.
ResearchSubject
Record of a subject's enrollment and participation in a research study.
ResourceLocation
URI where data can be found.
ResourceSize
Number of bytes of content in the resource (if url provided)
RespiratoryRate
The rate of breathing (inhalation and exhalation) measured within in a unit time, expressed as breaths per minute.
ResultAchieved
The actual value or status achieved.
ResultTargeted
The desired value or status to be achieved.
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.
RouteIntoBody
The way a substance enters an organism after contact, particularly, the route of drug administration.
S-PhaseFraction
An expression of the number of mitoses found in a stated number of cells. The S-phase fraction number tells you what percentage of cells in the tissue sample are in the process of copying their genetic information (DNA). This S-phase, short for synthesis phase, happens just before a cell divides into two new cells. ReferenceRange: Low <6, Intermediate 6-10, >10 High.
SampledData
Data that comes from a series of measurements taken by a device, which may have upper and lower limits. The data type also supports more than one dimension in the data.
SecurityLabel
A code that connects the entry to a security policy. Security labels can be updated when the resource changes, or whenever the security sub-system chooses to.
SemiquantDuration
The duration of an event, described semi-quantitatively.
SemiquantFrequency
The frequency of an event, described semi-quantitatively.
SequenceNumber
The sequence number for this specimen in a collection of specimens.
SeriousAdverseEvent
Clinical significance of adverse event usually associated with events that pose a threat to a patient's life or functioning. Seriousness of adverse event serves as a primary guide for defining regulatory reporting obligations and changes in medicinal product development and usage.
ServiceConnectedDisability
Percentage disability resulting from US Military Service.
ServiceGiven
Indicates a medical service provided.
ServiceProvider
The organization that provided the services rendered during this encounter.
Setting
Description of the place or type of surroundings where something is positioned or where an event takes place.
Severity
Degree of harshness or extent of a symptom, disorder, or condition.
SexualActivity
Characterization of the sexual activity of the subject.
SexualBehavior
Experience with sexual intercourse.
SexualIdentity
Information on gender identity and sexual orientation.
SexualOrientation
An inherent and enduring emotional, romantic or sexual attraction to other people.
ShrId
A unique, persistent, permanent identifier for the overall health record belonging to the PersonOfRecord.
Signatory
The party signing.
Signature
A digital Signature - XML DigSig, JWT, Graphical image of signature, etc.
SimpleQuantity
A quantity where the comparator is not used, as defined in FHIR
SizeOfGrossTumorBed
The largest dimension of the gross tumor bed/fibrotic area.
SleepQualityCause
Reason for poor sleep quality.
SleepQualityPanel
Self-reported sleep quality.
SocialEnvironment
Factors affecting the health of the subject in their daily living environment.
SocialSecurityNumber
A US social security number (SSN).
SourceSpecimen
Identifier for the source specimen from which this specimen was derived.
SpecialHandling
Information about the proper handling of the specimen.
SpecializedFinding
The base class for conditions, allergies, risks, etc. The type/topic of the finding is given by the concept code for the class. For example, for Condition, the finding represents a 'condition present' finding, while the Value represents the type of condition found. For this reason, a separate ObservationCode is not required for descendants of SpecializedFinding.
SpecificLaboratoryTest
The specific test code and additional details. The test name is part of the CodeableConcept.
Specimen
Sample for analysis
SpecimenCollectionAction
Attribution specific to the collection of a specimen.
SpecimenCollectionPerformed
SpecimenCollectionRequested
SpecimenContainer
Direct container of specimen (tube&#47;slide, etc.)
SpecimenQuantity
Quantity of specimen within container.
SpecimenTreatment
Treatment performed on the specimen.
SpecimenType
Kind of material that forms the specimen
SpokenLanguageProficiency
Accuracy and fluency in spoken communication in a language.
Sponsor
The organization responsible for the execution of the study.
Stage
The relative advancement in the course of a disease.
StagingSystem
What staging system are used
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.
StainingControl
Whether control cells were present.
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.
Statistic
A quantity that represents a statistic, e.g. maximum, minimum, mean, median, etc.
StatisticType
The type of statistic that is represented by the value.
Status
Position in workflow.
Study
A clinical trial or similar research study. Reference: list of FDA data elements describing a research study: prsinfo.clinicaltrials.gov/definitions.html
StudyArm
Arm refers to pre-specified group or subgroup of participant(s) in a clinical trial assigned to receive specific intervention(s) (or no intervention) according to a protocol.
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.
Substance
Any matter of defined composition that has discrete existence, whose origin may be biological, mineral or chemical.
SubstanceAbuseTreatment
The treatment program used to address a substance abuse problem.
SubstanceCategory
Categorization of the risk substance as a food, drug, or environmental agent. For difficult-to-classify substances, one can leave this field empty or choose the most typical category.
SubstanceOrCode
A substance entity or a substance code.
SubstanceUse
Assertion concerning the past or current use of a substance (alcohol, recreational drugs, illegal drugs, or abuse of prescription medication) that could negatively impact the subject's health.
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.
SupportSurface
A specific instance of a support surface used to distribute pressure and support a patient. The value is coding of the type of support surface.
SupportSurfaceBodyPosition
What body positions the surface can be used for, specifically, sitting or lying.
SupportSurfaceCategory
The category of support surface.
SupportSurfaceComponent
A physical material, structure, or system used alone or in combination with other components to fashion a support surface.
SupportSurfaceUsed
A paricular instance of the use of a support surface in patient care.
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.
SurgicalProcedure
A surgical action, independent of action context.
SurgicalProcedureNotPerformed
SurgicalProcedurePerformed
SurgicalProcedureRequested
SurgicalProcedureRequestedAgainst
SystolicPressure
The blood pressure during the contraction of the left ventricle of the heart, when blood pressure is at its highest.
T-Stage
The size and extent of the primary tumor (greatest dimension), based on criteria from the American Joint Committee on Cancer. See Table 152 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm
Tag
A code used to relate entries to categories or workflows. Applications are not required to consider the tags when interpreting the meaning of an entry.
TelecomNumberOrAddress
A user name or other identifier on a telecommunication network, such as a telephone number (including country code and extension, if necessary), email address, or SkypeID.
TerminationReason
A description and/or code explaining the premature termination of the study.
TimeOfDay
Time of day the event should take place on the designated day(s). TimeOfDay should only be specified if the RecurrenceInterval and/or DayOfWeek establishes the day when the event should take place.
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.
TimePeriodEnd
The time at which something is to end or did end. Boundary is considered inclusive.
TimePeriodStart
The time at which something is to take effect, start, or did start. Boundary is considered inclusive.
Timing
A timing schedule that specifies an event that may occur multiple times. Timing offers a choice of multiple OccurrenceTime (used is used to specify specific times), or recurrence patterns.
TimingCode
A code for the timing schedule. Some codes such as BID are ubiquitous, but many institutions define their own additional codes. If a code is provided, the code is understood to be a complete statement of whatever is specified in the structured timing data, and either the code or the data may be used to interpret the Timing, with the exception that .repeat.bounds still applies over the code (and is not contained in the code).
TimingOfDoses
When doses of medication should be administered.
Title
A distinguishing word or group of words naming an item.
TNMStage
The stage of a cancer, assessed according to the standard established by American Joint Committee on Cancer (AJCC). TNM Stage Grouping categorizes the progression of cancer using the Roman Numeral system. See Table 140 in HL7 CDA® R2 Implementation Guide: Clinical Oncology Treatment Plan and Summary, Release 1 - US Realm
ToxicReaction
A grade 3 or 4 adverse reaction to medication, radiation treatment, or other therapy.
TransportationAvailability
Whether the subject has reliable transportation to bring him or her to medical appointments and to get medications.
Travel
Trip to a foreign country or an area, particularly when a health risk is involved.
TreatmentCooperation
Whether the patient is undergoing treatment voluntarily, or under a legal order.
TroubleFallingAsleep
How often the subject has trouble falling asleep.
TroubleStayingAsleep
How often the subject has trouble staying asleep.
TubuleFormationScore
A comparison between structures formed by the tumor cells as opposed to those formed by normal cells. Scored 1 to 3 with 3 being the most abnormal.
TumorDimensions
TumorMarginDescription
Description of the edge or border of tumor in situ by radiologist or of removed tumor by pathologist.
TumorMargins
The edge or border of the tissue removed in cancer surgery. The margin is described as negative or clean when the pathologist finds no cancer cells at the edge of the tissue, suggesting that all of the cancer has been removed. The margin is described as positive or involved when the pathologist finds cancer cells at the edge of the tissue, suggesting that all of the cancer has not been removed.
TumorPrimaryDimensionSize
The longest diameter of the primary tumor.
TumorSecondaryDimensionSize
The longest perpendicular diameter of the primary tumor.
Type
The most specific code (lowest level term) describing the kind or sort of thing being represented.
TypeAsaCoding
UnitedStatesAddress
An address for a place in the USA, conforming to US mail postal conventions. (Source: HL7 FHIR).
UnitedStatesState
A state or territory in the USA expressed by 2-letter US Postal code.
Units
Code for the unit of measure of the quantity.
UpperBound
The upper limit on a quantitative value.
UpperLimit
The upper limit of detection of the measured points. This is needed if any of the data points have the value 'U' (higher than detection limit).
UsingAccessDevice
The access device used to perform the procedure.
UsingAccessDeviceCode
The access device used to perform the procedure.
UsingDevice
The device used to perform the procedure.
UsingDeviceCode
The device used to perform the procedure.
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.
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).
VendorModelNumber
The model number of the device, assigned by the manufacturer or vendor.
VerificationStatus
Whether an assessment has been confirmed by testing or observation.
Version
A string identifying the particular of form of something (such as a code system or software product) that is different in some way from another form of the same thing.
ViolentRiskToOthers
Risk or danger posed by the focal subject to others.
ViolentRiskToSelf
Risk or danger posed by the focal subject to his or herself.
VisibleInternalStructure
An internal body structure visible from outside the body, for example, due to injury.
VitalSign
Volume
The amount of three dimensional space occupied by an object or the capacity of a space or container.
WakeFeelingRested
How often the subject feels rested when they wake up.
WhenClinicallyRecognized
The time at which a condition or condition was first identified in a healthcare context.
Width
The measurement or extent of something from side to side.
Wound
A determination that a wound that exists at a particular body site, implicitly, the wound itself. Multiple wound assessments can be associated with a single wound.
WoundAbsent
Documents the absence of a wounds of a particular type at a given body site. if the Value is SCT#416462003 (Wound) then there is no wound of any type at the site.
WoundAssessmentPanel
Group of observations regarding the properties and severity of a wound.
WoundBedAndEdge
Description of the periphery and base of a wound.
WoundEdgeAppearance
Evaluation of the state of the tissue at the edge of the wound.
WoundExudate
Description of the fluid produced by a wound.
WoundSize
The estimated or measured dimensions of a wound.
WoundTunneling
A discharging blind-ended track that extends from the surface of an organ to an underlying area or abscess cavity. The track is invariably lined with granulation tissue. In chronic cases this may be augmented with epithelial tissue.
WoundUndermining
Assessment of deep tissue (subcutaneous fat and muscle) damage around the wound margin. Tunneling is just under the skin surface and doesn't involve deep tissue, and sinus tracts are a narrow tract that are away from the wound margins and go downward into the wound.
WrittenLanguageProficiency
Accuracy and fluency of reading and writing in a language.
SHR Reference Model