clinicalDataSourcePointer to information about who provided the information about a clinically relevant assertion and the circumstances surrounding that information provision.
contentVersion"The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted." - HL7 FHIR, Meta.versionId
contextCode"The ontological status of the statement, e.g., whether it exists, does not exist, is planned, etc. Attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) Concept Model context attributes: 'Finding context (attribute)' (SCTID: 408729009) and 'Procedure context (attribute)' (SCTID: 408730004). The range allowed for this attribute shall be consistent with the SNOMED CT concept model specification for SWEC." - HL7 CIMI, StatementContext.contextCode
cosigned"Provenance information specific to the cosigning of the clinical statement." - HL7 CIMI, InformationEntry.cosigned
encounterPointer to the Encounter during which the Action or Observation occurred. When used by the Condition Statement sub-type, this is the Encounter during which the Condition was first asserted."Encounter associated with this clinical statement." - HL7 CIMI, ClinicalStatement.encounter"The encounter when the allergy or intolerance was asserted." - HL7 FHIR, AllergyIntolerance.encounter"The Encounter during which this CarePlan was created or to which the creation of this record is tightly associated." - HL7 FHIR, CarePlan.encounter"The Encounter during which this Communication was created or to which the creation of this record is tightly associated." - HL7 FHIR, Communication.encounter"The Encounter during which this CommunicationRequest was created or to which the creation of this record is tightly associated." - HL7 FHIR, CommunicationRequest.encounter"Encounter during which the condition was first asserted." - HL7 FHIR, Condition.context"The Encounter during which this [Event sub-type] was created or to which the creation of this record is tightly associated." - HL7 FHIR, Event.encounter pattern."The visit or admission or other contact between patient and health care provider the immunization was performed as part of." - HL7 FHIR, Immunization.encounter"The visit, admission, or other contact between patient and health care provider during which the medication administration was performed." - HL7 FHIR, MedicationAdministration.context"The encounter or episode of care that establishes the context for this event." - HL7 FHIR, MedicationDispense.context"A link to an encounter, or episode of care, that identifies the particular occurrence or set occurrences of contact between patient and health care provider." - HL7 FHIR, MedicationRequest.context"The encounter or episode of care that establishes the context for this MedicationStatement." - HL7 FHIR, MedicationStatement.context"The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made." - HL7 FHIR, Observation.encounter"The encounter during which the procedure was performed." - HL7 FHIR, Procedure.encounter"The Encounter during which this questionnaire response was created or to which the creation of this record is tightly associated." - HL7 FHIR, QuestionnaireResponse.encounter"The Encounter during which this [Request sub-type] was created or to which the creation of this record is tightly associated." - HL7 FHIR, Request.encounter pattern."The encounter where the assessment was performed." - HL7 FHIR, RiskAssessment.encounterThis is the visit associated with this surgery case. [FileMan 130,.015]
notePointer to any remarks concerning the clinical information. This construct allows multiple (i.e., zero to many) clinicians to comment upon the clinical information, perhaps over time. For example, the data enterer may provide some comments and later the verifier may also record some additional comments. In addition, it allows the same clinician to provide multiple comments, likely over time."This field is for reporting additional comments related to the sample." - HL7 Version 2.8, OBR-39."Unstructured notes appended to a clinical statement." - HL7 CIMI, InformationEntry.additionalText"Additional narrative about the propensity for the Adverse Reaction, not captured in other fields." - HL7 FHIR, AllergyIntolerance.note"General notes about the care plan not covered elsewhere." - HL7 FHIR, CarePlan.note"Additional notes or commentary about the communication by the sender, receiver or other interested parties." - HL7 FHIR, Communication.note"Comments made about the request by the requester, sender, recipient, subject or other participants." - HL7 FHIR, CommunicationRequest.note"Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis." - HL7 FHIR, Condition.note"Details about the device statement that were not represented at all or sufficiently in one of the attributes provided in a class. These may include for example a comment, an instruction, or a note associated with the statement." - HL7 FHIR, DeviceUseStatement.note"Comments made about the [Event sub-type] by the performer, subject or other participants." - HL7 FHIR, Event.note pattern."This property allows a non condition-specific note to the made about the related person. Ideally, the note would be in the condition property, but this is not always possible." - HL7 FHIR, FamilyMemberHistory.note"An area where general notes can be placed about this specific condition." - HL7 FHIR, FamilyMemberHistory.condition.note"Extra information about the immunization that is not conveyed by the other attributes." - HL7 FHIR, Immunization.note"Extra information about the medication administration that is not conveyed by the other attributes." - HL7 FHIR, MedicationAdministration.note"Extra information about the dispense that could not be conveyed in the other attributes." - HL7 FHIR, MedicationDispense.note"Provides extra information about the medication statement that is not conveyed by the other attributes." - HL7 FHIR, MedicationStatement.note"May include statements about significant, unexpected or unreliable values, or information about the source of the value where this may be relevant to the interpretation of the result." - HL7 FHIR, Observation.note"Any other notes and comments about the procedure." - HL7 FHIR, Procedure.note"Comments made about the [Request sub-type] by the requester, performer, subject or other participants." - HL7 FHIR, Request.note pattern."Additional comments about the risk assessment." - HL7 FHIR, RiskAssessment.note"To communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen)." - HL7 FHIR, Specimen.note
recorded"Provenance information specific to the recording of the clinical statement (e.g., when recorded, where recorded, etc...)." - HL7 CIMI, InformationEntry.recorded"Individual who recorded the record and takes responsibility for its content." - HL7 FHIR, AllergyIntolerance.recorder"When populated, the author is responsible for the care plan. The care plan is attributed to the author." - HL7 FHIR, CarePlan.author"Individual who recorded the record and takes responsibility for its content." - HL7 FHIR, Condition.recorder"The date the occurrence of the [Event sub-type] was first captured in the record - potentially significantly after the occurrence of the event." - HL7 FHIR, Event.recorded pattern."Individual who recorded the record and takes responsibility for its content." - HL7 FHIR, Procedure.recorder"Person who received the answers to the questions in the QuestionnaireResponse and recorded them in the system." - HL7 FHIR, QuestionnaireResponse.author
recordStatusThe state of the Clinical Information record, as defined in the state-transition model in the HL7 RIM. Possible values include: Aborted, Active, Cancelled, Completed, Held, New, Nullified, Obsolete. Note that this property represents the state of the clinical record, not the state of the thing being recorded (which is an especially important distinction when dealing with Observations). When the state of the thing being observed is needed (e.g., in remission), a separate property, such as clinicalStatus, will be used. Note also that VistA and RPMS have the concept of being "Entered in Error" which is equivalent to a status of Nullified. For the Condition subtype of Observation, this property summarizes the current state of the Condition (or subtype such as Health Concern (aka Problem) or Intolerance Condition), as indicated by the last observation made on the Condition."Indicates the verification status for the allergy." - HL7 Version 2.8, IAM-17. HL7 Version 2 has the following suggested values (table 438): Unconfirmed; Pending; Suspect; Confirmed or verified; Confirmed but inactive; Erroneous; Doubt raised."Contains the observation result status.... This field reflects the current completion status of the results for one Observation Identifier...." - HL7 Version 2.8, OBX-11."Contains the current status of the problem at this particular date/time (e.g., active, active-improving, active-stable, active-worsening, inactive, resolved, etc.)." - HL7 Version 2.8, PRB-14"Concept indicating the state of this record. E.g., entered in error." - HL7 CIMI InformationEntry.recordStatus"A code representing the patient or other source's judgment about the state of the device used that this statement is about. Generally this will be active or completed." Possible values are: Active; Completed; Entered in Error; Intended; Stopped; On Hold (aka Suspended). - HL7 FHIR, DeviceUseStatement.status"The current state of the [Event sub-type]." Possible values are: Preparation; In Progress; Not Done; On Hold; Stopped; Completed; Entered in Error; Unknown - HL7 FHIR, Event.status pattern."Indicates the current status of the immunization event." - HL7 FHIR, Immunization.status"Will generally be set to show that the administration has been completed. For some long running administrations such as infusions, it is possible for an administration to be started but not completed or it may be paused while some other process is under way." - HL7 FHIR, MedicationAdministration.status"A code specifying the state of the set of dispense events." - HL7 FHIR, MedicationDispense.status"A code specifying the state of the procedure. Generally, this will be the in-progress or completed state." - HL7 FHIR, Procedure.status"The position of the questionnaire response within its overall lifecycle." - HL7 FHIR, QuestionnaireResponse.status
relatedClinicalInformationPointer to other Clinical Information record(s) to which this Clinical Information record is related in some manner."A care plan that is fulfilled in whole or in part by this care plan." - HL7 FHIR, CarePlan.basedOn"A larger care plan of which this particular care plan is a component or step." - HL7 FHIR, CarePlan.partOf"Completed or terminated care plan whose function is taken by this new care plan." - HL7 FHIR, CarePlan.replaces"Related observations - either components, or previous observations, or statements of derivation." - HL7 FHIR, Observation.related."A procedure or observation that this questionnaire was performed as part of the execution of. For example, the surgery a checklist was executed as part of." - HL7 FHIR, QuestionnaireResponse.partOf"Completed or terminated request(s) whose function is taken by this new [Request sub-type]." - HL7 FHIR, Request.replaces pattern."A reference to a resource that this risk assessment is part of, such as a Procedure." - HL7 FHIR, RiskAssessment.parentAn additional operative procedure performed by a different surgical team under the same anesthetic which has a CPT code different from that of the Principal Operative Procedure (e.g., fixation of a femur fracture in a patient undergoing a laparotomy for trauma). [FileMan 130,35]
signed"Provenance information specific to the signing of the clinical statement." - HL7 CIMI InformationEntry.signed"The healthcare professional responsible for authorizing the initial prescription." - HL7 FHIR, MedicationRequest.requester.agent"Individual who is making the procedure statement." - HL7 FHIR, Procedure.asserter
sourceRecordTypeThis optional property may be used to categorize the medical record, especially in terms of (or from the point of view of) the originating computer system. It is anticipated that it will become increasingly commonplace for records from multiple systems and organizations will be comingled in order to provide a complete picture of the patient's health record; therefore information about the source and type of information will be helpful. This property is modeled as a string because we do not anticipate a commonly-agreed-upon controlled vocabulary to be available, however implementers may choose to implement this as a code using a locally-defined vocabulary. Added 1/23/2015.
sourceSystemIdentifies the computer system that created the medical record. This optional field may also be used to indicate that the medical record was originally created by a different organization from the one that is currently storing or utilizing the record in that the assigning authority of the Id could be set to that originating organization. This property is optional, as some systems will assume that all records that it contains originated in that system, however it is anticipated that it will become increasingly commonplace for records from multiple systems and organizations will be comingled in order to provide a complete picture of the patient's health record. Added 1/23/2015.
subjectGroupIn FHIR, the subject of the Clinical Statement can often be a Patient or a Group of patients (for example, a group counselling session). In those cases where the Clinical Statement is about a Group of patients, this property identifies the group (which then points to the set of individual patients). This property is mutually exclusive with the subjectOfRecord property: if one is populated, the other must be empty."The patient or group that was the focus of this communication." - HL7 FHIR, Communication.subject"The patient or group that is the focus of this communication request." - HL7 FHIR, CommunicationRequest.subject"Indicates the patient or group who the condition record is associated with." - HL7 FHIR, Condition.subject"The individual or set of individuals the action is being or was performed on." - HL7 FHIR, Event.subject pattern."The person or animal or group receiving the medication." - HL7 FHIR, MedicationAdministration.subject"A link to a resource representing the person or the group to whom the medication will be given." - HL7 FHIR, MedicationDispense.subject"The person, animal or group who is/was taking the medication." - HL7 FHIR, MedicationStatement.subject"The patient, or group of patients, location, or device whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. Comments: Indirect characteristics may be those of a specimen, fetus, donor, other observer (for example a relative or EMT), or any observation made about the subject." - HL7 FHIR, Observation.subject"The person, animal or group on which the procedure was performed." - HL7 FHIR, Procedure.subject"The subject of the questionnaire response. This could be a patient, organization, practitioner, device, etc. This is who/what the answers apply to, but is not necessarily the source of information." - HL7 FHIR, QuestionnaireResponse.subject"The individual or set of individuals the action is to be performed/not performed on or for." - HL7 FHIR, Request.subject pattern."The patient or group the risk assessment applies to." - HL7 FHIR, RiskAssessment.subject
subjectOfInformationPointer to the entity which is the subject of the Clinical Information. In the majority of cases the subject of the clinical information is the same as the patient in whose record the clinical information is stored. But in a few cases, the subject of the clinical information may be different than the patient. For example, the blood type of a fetus is stored in the mother's medical record. In this case the "subject of record" is the mother, while the "subject of information" is the fetus. In addition, this association can be used when an observation is made where there is no patient. For example, environmental samples, or a foodstuff sample for food safety testing. Note that this property will only be used when the patient is not the subject of the clinical activity. When the patient is the subject of the clinical information, which again is the majority of the cases, this property will not be used."The entity being described by this statement. The entity may be animate (a patient, a relative of the patient, a veterinary patient, a cohort) or inanimate (a well, a geographical location). The subject of information is constrained in archetypes. This attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) and is bound to the SNOMED attribute: |408732007|Subject relationship context (attribute)." - HL7 CIMI InformationEntry.subjectOfInformation"The actual focus of an observation when it is not the patient of record. The focus is point of attention when the observation representing something or someone associated with the patient. It could be a spouse or parent, a fetus or donor. The focus of an observation could be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus." - HL7 FHIR, Observation.focus
subjectOfRecordPointer to the (Person or Animal in the Role of) Patient which is the "record target" for the Clinical Information. In the majority of cases the subject of the clinical information is the same as the patient in whose record the clinical information is stored. But in a few cases, the subject of the clinical information may be different than the patient. For example, the blood type of a fetus is stored in the mother's medical record. In this case the "subject of record" is the mother, while the "subject of information" is the fetus."The patient who has the allergy or intolerance." - HL7 FHIR, AllergyIntolerance.patient"The patient or group that was the focus of this communication." - HL7 FHIR, Communication.subject"The patient or group that is the focus of this communication request." - HL7 FHIR, CommunicationRequest.subject"Indicates the patient or group who the condition record is associated with." - HL7 FHIR, Condition.subject"The patient who used the device." - HL7 FHIR, DeviceUseStatement.subject"The individual or set of individuals the action is being or was performed on." - HL7 FHIR, Event.subject pattern."The person who this history concerns." - HL7 FHIR, FamilyMemberHistory.patient"The patient who either received or did not receive the immunization." - HL7 FHIR, Immunization.patient"The person or animal or group receiving the medication." - HL7 FHIR, MedicationAdministration.subject"A link to a resource representing the person or the group to whom the medication will be given." - HL7 FHIR, MedicationDispense.subject"The person, animal or group who is/was taking the medication." - HL7 FHIR, MedicationStatement.subject"The patient, or group of patients, location, or device whose characteristics (direct or indirect) are described by the observation and into whose record the observation is placed. Comments: Indirect characteristics may be those of a specimen, fetus, donor, other observer (for example a relative or EMT), or any observation made about the subject." - HL7 FHIR, Observation.subject"The person, animal or group on which the procedure was performed." - HL7 FHIR, Procedure.subject"The subject of the questionnaire response. This could be a patient, organization, practitioner, device, etc. This is who/what the answers apply to, but is not necessarily the source of information." - HL7 FHIR, QuestionnaireResponse.subject"The individual or set of individuals the action is to be performed/not performed on or for." - HL7 FHIR, Request.subject pattern."The patient or group the risk assessment applies to." - HL7 FHIR, RiskAssessment.subject
temporalContext"Whether the topic is prospective or retrospective. E.g., action occurred in the past. This attribute is aligned with the SNOMED Situation With Explicit Context temporal context attribute." - HL7 CIMI, StatementContext.temporalContext
topicCodeThis property represents the kind of finding or action that is being described by the Clinical Statement. It has its origin in CIMI's notion of assembling clinical statements from a topic and a context, so that each might be treated more consistently across medical records. It has the additional benefit of the topic being a pointer into the appropriate terminology (e.g., SNOMED). The separation of topic and context allow one to build the equivalent Situation with Explicit Context construct using SNOMED. In practical terms, this means that every observation (e.g., serum sodium, heart rate, etc.) will use this property to define what is being observed. Similarly, every procedure (e.g., appendectomy proposed, appendectomy performed) will also use this property to define the procedure (i.e., appendectomy)."The concept representing the finding or action that is the topic of the statement. For actions, the key represents the action being described. For findings, the key represents the "question" or property being investigated. For evaluation result findings, the key contains a concept for an observable entity, such as systolic blood pressure. For assertion findings (which by nature lack an explicit question), the key contains a default concept signifying that an assertion is being made. In all cases, the key describes the topic independent of the context of the action or the finding." - HL7 CIMI, StatementTopic.topicCode"Describes what was observed. Sometimes this is called the observation "name"." - HL7 FHIR, Observation.code"The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g., Laparoscopic Appendectomy)." - HL7 FHIR, Procedure.code
verified"Provenance information specific to the verification process associated with this statement (e.g., verifier, verification method, when verified, etc.)" - HL7 CIMI InformationEntry.verified
