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Base

The SHR Base domain contains definitions for elements that are widely shared in SHR, including the base Entry and associated metadata.

AccessTime

Point in time when data was accessed.

Value:  dateTime

Action

A deed or endeavor; an action taken to address a undesired health state, behavior, risk, or goal. An action can have various contexts: definitional, occurred/not occurred, ordered/not ordered, recommended/recommended against.

SpecificType optional A code or description representing the concept represented by the instance at a specific level. For example, for a Condition, the concept is MTH#C0348080 (Condition) but the Value is the SpecificType, i.e. MTH#C0011849 (Diabetes Mellitus). For an observation, the SpecificType defines what is being observed, measured, or asked, as specifically as possible. The SpecificType should always align with the concept of the element, for example, a blood pressure observation can be coded as a sitting blood pressure or standing blood pressure, and may be from a different code system (e.g. LOINC versus MTH). In other cases, the SpecificType is the specific question being asked, or the specific goal being pursued.
Status required The position of affairs at a particular time
Category 0 or more A categorization of the action according its type, often a code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This can be used for searching, sorting and display purposes.
NonOccurrenceModifier optional When true, indicates either that the event or action documented in the entry did not occur. For example, if immunization is not given, the NonOccurrenceModifier=true will indicate this. When applied to a recommendation, the modifier indicates the action mentioned in the topic should not take place. For example, a request to NOT elevate the head of a bed using the code for elevating the bed, and setting ProhibitedModifier to true. Other examples include do not ambulate, do not flush NG tube, do not take blood pressure on a certain arm, etc. If the SpecificType contains negation and ProhibitedModifier is true, that will reinforce the prohibition, and should not be interpreted as a double negative that equals a positive.
Reason 0 or more The justification for an action or non-action, conclusion, opinion, etc.
OccurrenceTime optional The point in time or span of time in which something happens.
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.

AssertionNegationModifier

When true, this modifier indicates that the associated observation, assessment, or finding is false, the condition is absent. For example, if the assessment is 'allergy to peanuts' and the AssertionNegationModifier is true, it means the subject does not have an allergy to peanuts.

Value:  boolean

AssociatedEncounter

The encounter or episode of care that led to creation of this entry.

Value:  Encounter A statement about a planned or actual interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Author

The person or organization who created the entry and is responsible for (and may certify) its content.

Value:  Choice
         |  PersonOfRecord required Extended demographic information about the subject of this SHR.
         |  Practitioner required A person who practices a healing art.
         |  RelatedPerson required A person, other than a practitioner or the patient (the person of record) who is relevant to the health or social situation of the subject.
         |  Organization required A social or legal structure formed by human beings.
         |  Device required 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.

Category

A categorization of the action according its type, often a code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This can be used for searching, sorting and display purposes.

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

Entry

An item inserted in an electronic record. C1705654

ShrId required A unique, persistent identifier for the Standard Health Record to which this entry belongs.
EntryId required A unique, persistent, permanent identifier for an entry in a health record.
Version optional 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.
EntryType 1 or more The SHR data element identifier, for example, http://standardhealthrecord.org/allergy/SubstanceRisk. 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.
FocalSubject required The person or thing that this entry refers to, usually the Person of Record. However, not all entries refer to the Person of Record. The entry could refer to a fetus, care giver, or relative (living or dead).
SubjectIsThirdPartyFlag optional If true, the subject of this entry is someone other than the Person of Record, for example, a family member.
Narrative optional 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.
Informant optional The person or entity that provided the information in the entry, as distinct from the actor creating the entry, e.g. the subject (patient), medical professional, family member, device or software program.
Author optional The person or organization who created the entry and is responsible for (and may certify) its content.
AssociatedEncounter optional The encounter or episode of care that led to creation of this entry.
OriginalCreationDate required The point in time when the information was recorded in the system of record.
LastUpdateDate required A date that the entry was changed.
Language optional A human language, spoken or written.
SecurityLabel (TBD) 0 or more Description TBD
Tag (TBD) 0 or more Description TBD

EntryId

A unique, persistent, permanent identifier for an entry in a health record. C0600091

Value:  id

EntryType

The SHR data element identifier, for example, http://standardhealthrecord.org/allergy/SubstanceRisk. 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.

Value:  uri

ExternalHealthRecord

A health record used to help populate the current health record.

OrganizationalIdentifier required Unique identifier of something or someone, assigned by an organization, and potentially effective for only a limited time period.
AccessTime required Point in time when data was accessed.

FocalSubject

The person or thing that this entry refers to, usually the Person of Record. However, not all entries refer to the Person of Record. The entry could refer to a fetus, care giver, or relative (living or dead).

Value:  Choice
         |  PersonOfRecord required Extended demographic information about the subject of this SHR.
         |  Practitioner required A person who practices a healing art.
         |  RelatedPerson required A person, other than a practitioner or the patient (the person of record) who is relevant to the health or social situation of the subject.

Informant

The person or entity that provided the information in the entry, as distinct from the actor creating the entry, e.g. the subject (patient), medical professional, family member, device or software program. C0449416

Value:  Choice
         |  PersonOfRecord required Extended demographic information about the subject of this SHR.
         |  Practitioner required A person who practices a healing art.
         |  RelatedPerson required A person, other than a practitioner or the patient (the person of record) who is relevant to the health or social situation of the subject.

Language

A human language, spoken or written. C0023008

Value:  CodeableConcept must be from http://hl7.org/fhir/ValueSet/languages A set of codes drawn from different coding systems, representing the same concept.

LastUpdateDate

A date that the entry was changed.

Value:  dateTime

MissingValueReason

The reason a required element, complex type, or primitive value is missing. Missing value reason can be substituted for any value. By convention in SHR, any required element or value can be substituted with a missing value reason.

Value:  CodeableConcept must be from MissingValueReasonVS A set of codes drawn from different coding systems, representing the same concept.

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.

Value:  xhtml
NarrativeQualifier required Additional information on how the narrative was generated, and the scope of information contained.

NarrativeQualifier

Additional information on how the narrative was generated, and the scope of information contained.

Value:  code must be from http://hl7.org/fhir/ValueSet/narrative-status

NonOccurrenceModifier

When true, indicates either that the event or action documented in the entry did not occur. For example, if immunization is not given, the NonOccurrenceModifier=true will indicate this. When applied to a recommendation, the modifier indicates the action mentioned in the topic should not take place. For example, a request to NOT elevate the head of a bed using the code for elevating the bed, and setting ProhibitedModifier to true. Other examples include do not ambulate, do not flush NG tube, do not take blood pressure on a certain arm, etc. If the SpecificType contains negation and ProhibitedModifier is true, that will reinforce the prohibition, and should not be interpreted as a double negative that equals a positive.

Value:  boolean
Reason optional The justification for an action or non-action, conclusion, opinion, etc.

OriginalCreationDate

The point in time when the information was recorded in the system of record. C3669169

Value:  dateTime

PatientInstructions

Information for the patient, such as, where to get the test, how to prepare for the test, etc.

Value:  string

PerformerInstructions

Information for the performer of the test, if needed.

Value:  string

PriorityOfRequest

Urgency level for which results must be reported to the requestor or responsible individual.

Value:  code must be from http://hl7.org/fhir/ValueSet/request-priority

Request

An order for something to take place. C1705178

Based On Action

Status must be from http://hl7.org/fhir/ValueSet/request-status required The position of affairs at a particular time
RequestedPerformanceTime optional 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.
Reason optional The justification for an action or non-action, conclusion, opinion, etc.
PriorityOfRequest optional Urgency level for which results must be reported to the requestor or responsible individual.
Choice optional
         |  RequestedPerformerType required What type of actor should carry out the testing.
         |  RequestedPerformer required Who should carry out the tests. For example, the patient or caregiver.
PerformerInstructions optional Information for the performer of the test, if needed.
PatientInstructions optional Information for the patient, such as, where to get the test, how to prepare for the test, etc.
SpecificType optional A code or description representing the concept represented by the instance at a specific level. For example, for a Condition, the concept is MTH#C0348080 (Condition) but the Value is the SpecificType, i.e. MTH#C0011849 (Diabetes Mellitus). For an observation, the SpecificType defines what is being observed, measured, or asked, as specifically as possible. The SpecificType should always align with the concept of the element, for example, a blood pressure observation can be coded as a sitting blood pressure or standing blood pressure, and may be from a different code system (e.g. LOINC versus MTH). In other cases, the SpecificType is the specific question being asked, or the specific goal being pursued.
Category 0 or more A categorization of the action according its type, often a code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This can be used for searching, sorting and display purposes.
NonOccurrenceModifier optional When true, indicates either that the event or action documented in the entry did not occur. For example, if immunization is not given, the NonOccurrenceModifier=true will indicate this. When applied to a recommendation, the modifier indicates the action mentioned in the topic should not take place. For example, a request to NOT elevate the head of a bed using the code for elevating the bed, and setting ProhibitedModifier to true. Other examples include do not ambulate, do not flush NG tube, do not take blood pressure on a certain arm, etc. If the SpecificType contains negation and ProhibitedModifier is true, that will reinforce the prohibition, and should not be interpreted as a double negative that equals a positive.
OccurrenceTime optional The point in time or span of time in which something happens.
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.

RequestedPerformanceTime

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.

Value:  Choice
         |  dateTime required
         |  date required
         |  TimePeriod required A period of time defined by a start and end time, date, or year.
         |  Timing (TBD) required Description TBD

RequestedPerformer

Who should carry out the tests. For example, the patient or caregiver.

Value:  Choice
         |  PersonOfRecord required Extended demographic information about the subject of this SHR.
         |  Practitioner required A person who practices a healing art.
         |  RelatedPerson required A person, other than a practitioner or the patient (the person of record) who is relevant to the health or social situation of the subject.
         |  Organization required A social or legal structure formed by human beings.

RequestedPerformerType

What type of actor should carry out the testing.

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

ShrId

A unique, persistent identifier for the Standard Health Record to which this entry belongs. C0600091

Value:  id

Status

The position of affairs at a particular time C0449438

Value:  Choice
         |  code required
         |  Coding required 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.
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.

Study [Entry]

A clinical trial or other formal study.

Title optional A distinguishing word or group of words naming an item.
Identifier optional A unique string that identifies a specific person or thing.

SubjectIsThirdPartyFlag

If true, the subject of this entry is someone other than the Person of Record, for example, a family member.

Value:  boolean