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

An action that either has or has not taken place.

ActionCode required The code for the action, such as an intervention or test, to be carried out.
NonOccurrenceModifier optional When true, indicates either that the event or action documented in the entry did not occur, or the the thing documented is absent or does not exist.
Reason optional 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.

ActionCode

The code for the action, such as an intervention or test, to be carried out.

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

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.

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).
SubjectIsThirdPartyModifier 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.

Identifier required A numeric or alphanumeric string that is associated with a single object or entity within a given system. Typically, identifiers are used to connect content in resources to external content available in other frameworks or protocols. Identifiers are associated with objects, and may be changed or retired due to human or system process and errors.
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 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 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 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, or the the thing documented is absent or does not exist.

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 from http://hl7.org/fhir/ValueSet/request-priority

Request

An order for something to take place. Using NonOccurrenceModifier, it may document why a request was NOT made. C1705178

Based On Action

RequestNotToPerformActionModifier optional If true, the thing requested 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 RequestNotToPerformActionModifier 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 Request.code and RequestAgainstModifier both contain negation, that will reinforce the prohibition, and should not be interpreted as a double negative that equals a positive.
RequestStatus required The extent to which the ordering process has progressed, for this order.
RequestedPerformanceTime optional When test or tests should be done. If the tests are a series or recur (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.
ActionCode required The code for the action, such as an intervention or test, to be carried out.
NonOccurrenceModifier optional When true, indicates either that the event or action documented in the entry did not occur, or the the thing documented is absent or does not exist.
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 test or tests should be done. If the tests are a series or recur (e.g. daily blood sugar testing in the morning) then a Timing can be used to describe the periodicity.

Value:  Choice
         |  dateTime 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.

RequestNotToPerformActionModifier

If true, the thing requested 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 RequestNotToPerformActionModifier 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 Request.code and RequestAgainstModifier both contain negation, 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.

RequestStatus

The extent to which the ordering process has progressed, for this order.

Value:  code from http://hl7.org/fhir/ValueSet/request-status

ShrId

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

Value:  id

SubjectIsThirdPartyModifier

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

Value:  boolean