HL7™ Clinical Information Model Initiative

Clinical Information Model Initiative (CIMI) Reference Model Specification

Welcome to the HL7 CIMI Reference Model Documentation Version 0.0.3 generated on Sat, 29 Jul 2017 21:54:54 -0700.

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Classes 
Classes Description
Absent
Context indicating the known absence of a finding in the subject of information. If the finding is suspected to be absent, use the known or suspected present context instead.
AbstractDurableEncounter
Contains properties common to multiple kinds of Encounters which last more than a few hours. Such encounters typically include an admission and discharge process.
Accreditation
Type supporting the capture of accreditation information.
ActionContext
The ActionContext class aligns with the SNOMED Situations with Explicit Context and provides the context for the Act topic of a clinical statement. For instance, a statement about a procedure may specify that the procedure has been proposed, ordered, planned, performed or possibly not performed.
ActorName
The name of an actor - typically either the name of a person or of an organization.
Admission
A record about the admission of a patient to a facility generally for the provision of care.
AdvanceDirective
Patient or proxy-supplied prospective instructions for treatment.
AdverseFindingReportEntry
An AdverseFinding is any unexpected clinical finding in a patient in the course of care or clinical investigation subject which does not necessarily have a causal relationship with a specific intervention.
AdverseReaction
An unintended physical injury resulting from exposure to a substance. Note that the manifestation of the adverse reaction is captured in FindingTopic.result attribute.
AdverseSensitivityToSubstance
Estimate of the potential clinical harm, or seriousness, of the reaction to the identified substance.
Age
Type for the capture of age-related information.
AMOUNT
Abstract class defining the concept of relative quantified amounts. For relative quantities, the +' and -' operators are defined.
AnatomicalLocation
A part of the body.
Annotation
Text node with optional attribution
Any
Abstract supertype. Usually maps to a type like “Any” or “Object” in an object system. Defined here to provide the value and reference equality semantics.
ARCHETYPED
Archetypes act as the configuration basis for the particular structures of instances defined by the reference model. To enable archetypes to be used to create valid data, key classes in the reference model act as root points for archetyping; accordingly, these classes have the archetype_details attribute set. An instance of the class ARCHETYPED contains the relevant archetype identification information, allowing generating archetypes to be matched up with data instances.
Array
physical container of items indexed by number
Assertion
Clinical Assertions assert the existence of clinical conditions, diseases, symptoms, etc. in the patient.
ASSOCIATION_CLASS
Abstract parent type for an association class.
Attribution
Attribution provides a formal pattern and reusable structure for attributes of a record that describes an activity in a process involved in producing, delivering or otherwise influencing that resource. Attribution provides a critical foundation for assessing authenticity, enabling trust, and allowing reproducibility. Provenance assertions are a form of contextual metadata and can themselves become important records with their own provenance. Provenance statement indicates clinical significance in terms of confidence in authenticity, reliability, and trustworthiness, integrity, and stage in lifecycle (e.g. Document Completion - has the artifact been legally authenticated), all of which may impact security, privacy, and trust policies. Attribution provides a common reference model pattern that may be included directly within a clinical statement (e.g., the metadata associated with the recording of a clinical statement in a system) or within the Provenance pattern when it is preferrable to have such information external to but referencing the clinical statement (see Provenance). Note that, when included directly within a clinical statement, updates made to attribution attribute values will result in a versioning change in the instance. When part of the Provenance class, updates to provenance do not result in an update of the clinical statement referenced by the Provenance class (see Provenance.target).
BASE_ACTOR
An entity acting as an actor assuming a role in a participation. For instance, a person may act as a provider in an encounter with a patient.
BASE_ENTITY
Parent class for all entities.
BASE_ROLE
Capacity in which an actor is involved in an activity. For instance, 'attending physician'.
BaseAddress
Base class for addresses to be specialized based on regional and realm-specific needs.
BaseAssertion
Base assertion class required for specialization hierarchies. Associates with a key='Assertion', a result with the specific assertion being made.
BaseEncounter
An abstract class that represents an encounter class.
BaseOrganizationName
The name of an organization.
BasePersonName
The base type for the name of a person. The name of a person can vary greatly across cultures and countries. Naming format variations are left to specializations of this class.
BiometricData
Type supporting the capture of biometric information.
BirthData
Type supporting the capture of birth-related information.
Boolean
logical True/False values; usually physically represented as an integer, but need not be
BradenAssessment
A Braden Assessment represents the Braden score used to assess an adult patient's susceptibility to skin breakdown. The summation of the scores range is from 6-23.
Byte
a type whose value is an 8-bit value.
Causality
An assessment of causality - i.e., whether the reaction was caused by exposure to the causative agent.
Character
a type whose value is a member of an 8-bit character-set (ISO: 'repertoire').
Citizenship
Type supporting the capture of citizenship information.
ClinicalStatement
The documentation of clinical information about a subject of information such as a patient or a relative of the patient, asserted by a particular source, recorded, and potentially verified. The ClinicalStatement class provides the core pattern for more specific clinical statement archetypes, such as a statement that a finding has been found in a patient or that a procedure has been proposed by a clinical decision support system. The ClinicalStatement pattern defines the core attributes common to most clinical statements and specifies a composition pattern that encourage model component reuse and better alignment with the SNOMED CT Concept Model. A clinical statement is composed of the StatementTopic class (grouping of attributes for capturing information about a procedure or a clinical finding) and the StatementContext class (grouping of attributes providing the context for the statement topic such as whether a procedure was performed, requested, not performed or whether a finding is suspected present or absent in the patient). At the archetype level, the topic and context components are coordinated to form the clinical statement. For instance, the composition of the ProcedureTopic with the NotPerformed context indicates that the given procedure was not performed.
ClinicalStatementAssociation
Association class used to represent the relationship between a class and one or more clinical statements where the relationship is qualified by one or more attributes.
ClinicalStudyAdverseFinding
An AdverseFinding is any unexpected clinical finding in a patient documented as part of a clinical investigation which does not necessarily have a causal relationship with a specific study intervention. For instance, a study participant developing a fever during the course of the study.
CLUSTER
Abstract class representing a reusable structure in a model such as an address or an entity such as a device.
CODED_TEXT
A text item whose value must be the rubric from a controlled terminology, the key (i.e. the code') of which is the code attribute. In other words: a CODED_TEXT is a combination of a CODE_PHRASE (effectively a code) and the rubric of that term, from a terminology service, in the language in which the data was authored. Since CODED_TEXT is a subtype of TEXT, it can be used in place of it, effectively allowing the type TEXT to mean a text item, which may optionally be coded. Misuse: If the intention is to represent a term code attached in some way to a fragment of plain text, CODED_TEXT should not be used.
CommonPersonName
Common human name format.
Component
The component abstract class is used to represent dependent observations, findings, or procedures associated with the parent clinical statement. A dependent component is a component that does not have an independent existence outside of its parent. For instance, the description of a wound bed must exist in the context of a wound assertion. However, a systolic blood pressure measurement can exist independently of a blood pressure panel. This distinction is important. Collections of independent statements should be represented using the composition structures offered by Compound Clinical Statement. Collections of dependent structures should be modeled using the Component pattern.
CompositeComponent
A component that itself can contain sub-components - e.g., the dimensional features of a wound or wound tunneling.
COMPOSITION
A composition is considered the unit of modification of the record, the unit of transmission in record extracts, and the unit of attestation by authorising clinicians. In this latter sense, it may be considered equivalent to a signed document.
CompoundClinicalStatement
Clinical statement representing multiple units of information that are treated as a whole such as a panel. A compound clinical statement is a collection of independent clinical statement, whether indivisible or compound. Note that complex medications are indivisible clinical statements even though their structure may be a composite data structure. They are generally treated as an independent entry in a record and their parts do not constitute independent entries in a record.
ContactInformation
Represents contact details such as an emergency contact or contact information for a next-of-kin.
CONTENT
Abstract ancestor of all concrete content types. A unit of content that makes up a composition - e.g., a clinical statement in a patient record, a simple or composite action is a knowledge document.
COUNT
Countable quantities. Used for countable types such as pregnancies and steps (taken by a physiotherapy patient), number of cigarettes smoked in a day. Misuse: Not to be used for amounts of physical entities (which all have units).
DATA_VALUE
Serves as a common ancestor of all CIMI complex types.
DATE
Represents an absolute point in time, as measured on the Gregorian calendar, and specified only to the day. Semantics defined by ISO 8601. Used for recording dates in real world time. The partial form is used for approximate birth dates, dates of death, etc.
DATE_TIME
Represents an absolute point in time, specified to the second. Semantics defined by ISO 8601. Used for recording a precise point in real world time, and for approximate time stamps, e.g. the origin of a HISTORY in an OBSERVATION which is only partially known.
DeathData
Information of about a death event.
DetailedAddress
A detailed address model.
DetailedPerson
An entity representing a person.
Device
This resource identifies an instance or a type of a manufactured item that is used in the provision of healthcare without being substantially changed through that activity. The device may be a medical or non-medical device. Medical devices includes durable (reusable) medical equipment, implantable devices, as well as disposable equipment used for diagnostic, treatment, and research for healthcare and public health. Non-medical devices may include items such as a machine, cellphone, computer, application, etc.
DeviceAssertion
An assertion about the use of a device. At this time, the class is a placeholder.
Diagnosis
The list of diagnosis relevant to this encounter where a diagnosis is defined as 'a.The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and/or review of laboratory data. b.The opinion derived from such an evaluation' American Heritage Dictionary
DimensionalFeature
Feature's physical attributes such as a growth or wound.
Discharge
A record pertaining to the discharge of a patient from an institution.
DispenseBase
Base class for dispense contexts.
DispenseEvent
Record of the dispensing event.
DispenseInstructions
Medication dispensing instructions for prospective clinical statements.
Dosage
Base class for medication dosage instruction and dosage event.
DosageEvent
Pattern for the dosing of a medication. Describes the medication dosage information details e.g. dose, rate, site, route, etc.
DosageInstruction
Pattern for the dosing of a medication. Describes how medication is to be administered or how it should be taken.
DURATION
Represents a period of time with respect to a notional point in time, which is not specified. A sign may be used to indicate the duration is backwards in time rather than forwards. NOTE a deviation from ISO8601 is supported, allowing the W' designator to be mixed with other designators. See assumed types section in the Support IM. Used for recording the duration of something in the real world, particularly when there is a need a) to represent the duration in customary format, i.e. days, hours, minutes etc, and b) if it will be used in computational operations with date/time quantities, i.e. additions, subtractions etc. Misuse: Durations cannot be used to represent points in time, or intervals of time.
EHR_URI
A EHR_URI is a URI which has the scheme name 'ehr', and which can only reference items in EHRs. Used to reference items in an EHR, which may be the same as the current EHR (containing this link), or another.
ElectronicContact
Data structure representing an electronic contact such as an email address.
EmergencyEncounter
Emergency is an encounter without a scheduled appointment and urgent clinical services are required.
EmployerRelationship
An employee relationship between a party and an organization.
ENCAPSULATED
Abstract class defining the common meta-data of all types of encapsulated data.
Encounter
An interaction between a patient and a practitioner under the auspices of a given organization for the purpose of providing healthcare-related service(s). It is important to understand that if the there is a change in provider or organization, by definition a new encounter will be generated. For example, if a patient is moved from Surgery to Post-Op, a new encounter is generated. Similarly, if a patient receives care from 2 nurses while in Post-Op, there will be 2 encounters.
Entitlement
Indicates characteristic of patient that may requires special consideration in handling or information disclosure - e.g., royalty, celebrity, felon, etc...
Entity
Root class for material entities such as anatomical locations, devices, and substances.
ENTRY
An ENTRY is the root of a logical item of hard clinical information created in the clinical statement context, within a clinical session or of clinical knowledge in a knowledge artifact. With regards to clinical information entries, there can be numerous such contexts in a clinical session. Observations and other Entry types only ever document information captured/created in the event documented by the enclosing Composition. An ENTRY is also the minimal unit of information any query should return, since a whole ENTRY (including subparts) records spatial structure, timing information, and contextual information, as well as the subject and generator of the information.
EvaluationResult
The outcome of an evaluation of a characteristic. This model holds a 'question' in the key and holds a value in the result. This value is further qualified through the model's properties.
EventContext
Context associated with non-clinical events such as floods, accidents, and tornadoes.
EventTopic
An non-clinical event such as a natural disaster. Topic allows the capture of information related to such events when they pertain to the clinical context associated with a given patient.
FindingContext
The FindingContext class aligns with the SNOMED Situation with Explicit Context for findings and provides the context for the EvaluationResult and Assertion topics of a clinical statement. For instance, a statement about findings may state that the finding was observed present or absent.
FindingSiteAssertion
An assertion about a finding found on the body.
FindingTopic
The characteristics looked for in medical investigations or diagnostics and the outcome.
GenericAddress
A generic address pattern that can be assembled from address parts. Note that this pattern will likely be deprecated in the future in favor of more expressive and extensible address specifications.
GenericOrganizationName
An organization name made up of component parts.
GenericPersonName
Person name composed of parts.
GeographicalLocation
Documentation missing
GoalContext
Clinical statement context for a goal.
HealthCareConsumerRole
Role assumed by an entity acting as a health care consumer.
HealthCareFacilityLocation
Documentation missing
HealthCareProviderIndividualRole
A healthcare provider role associated with a person.
HealthCareProviderOrganizationRole
A non-person health care entity such as a medical group or other organization.
HealthCareProviderRelationship
A relationship between an actor and a healthcare provider.
HealthCareProviderRole
Role associated with the delivery of health care as opposed to a consumer of health care.
HomeBasePrimaryCareEncounter
Patient is being treated 'In-Home' for this encounter.
Hospice
A hospice encounter.
IDENTIFIER
Type for representing identifiers of real-world entities. Typical identifiers include drivers licence number, social security number, veterans affairs number, prescription id, order id, and so on.
ImagingProcedure
Experimental class for an imaging procedure. Note that this class is still incomplete at this time.
IndivisibleClinicalStatement
The documentation of clinical information about a subject of information such as a patient or a relative of the patient, asserted by a particular source, recorded, and potentially verified. The ClinicalStatement class provides the core pattern for more specific clinical statement archetypes, such as a statement that a finding has been found in a patient or that a procedure has been proposed by a clinical decision support system. The ClinicalStatement pattern defines the core attributes common to most clinical statements and specifies a composition pattern that encourage model component reuse and better alignment with the SNOMED CT Concept Model. A clinical statement is composed of the StatementTopic class (grouping of attributes for capturing information about a procedure or a clinical finding) and the StatementContext class (grouping of attributes providing the context for the statement topic such as whether a procedure was performed, requested, not performed or whether a finding is suspected present or absent in the patient). At the archetype level, the topic and context components are coordinated to form the clinical statement. For instance, the composition of the ProcedureTopic with the NotPerformed context indicates that the given procedure was not performed.
Industry
Type representing an industry.
InformationEntry
Documentation missing
Ingredient
A components that go to make up the described item.
InpatientEncounter
Patient has been admitted to the facility and assigned a bed.
INSTANT
An instant in time - known at least to the second and always includes a time zone. Note: This is intended for precisely observed times (typically system logs etc.), and not human-reported times - for them, use date and dateTime. instant is a more constrained dateTime
Integer
An integer type
Interpretation
The interpretation provided by the containing type for the set of clinical statements that comprise the target of the relationship. For instance, Assertion.interpretation can be interpreted as follows: the assertion interprets the set of clinical statements specified as the range of Assertion.interpretation.target and the interpretation is specified by the Assertion.interpretation.hasInterpretation code.
INTERVAL_VALUE
Generic class defining an interval (i.e. range) of a comparable type. An interval is a contiguous subrange of a comparable base type. Used to define intervals of dates, times, quantities (whose units match) and so on. The type parameter, T, must be a descendant of the type ORDERED_VALUE, which is necessary (but not sufficient) for instances to be compared (strictly_comparable is also needed). The basic semantics are derived from the class Interval<T>, described in the support RM.
Justification
Asserted clinical justification to perform or not perform an act such as a diagnostic test, a medication treatment, or a procedure. The justification can be specified as a code or as a clinical statement, e.g., code for diabetes (ICD-9-CM 250.0) or a Condition occurrence statement (with diabetes code) documented elsewhere in a patient's record.
KnownOrSuspectedPresent
Context indicating that finding is known present or suspected present.
LaboratoryProcedure
Specialization of Procedure that represents a procedure performed on a collected specimen such as a blood panel or a biopsy.
LaboratoryTestResult
Measurement resulted from a laboratory.
LanguageCapability
Type representing proficiency in a language.
List
container of items, implied order, non-unique membership
LOCATABLE
Most classes in the CIMI reference model inherit from the LOCATABLE class, which defines the idea of 'locatability in an archetyped structure'. LOCATABLE defines a runtime name and an archetype_node_id. The archetype_node_id is the standardised semantic code for a node and comes from the corresponding node in the archetype used to create the data. The only exception is at archetype root points in data, where archetype_node_id carries the archetype identifier in string form rather than an interior node id from an archetype. LOCATABLE also provides the attribute archetype_details, which is non-Void for archetype root points in data, and carries meta-data relevant to root points. The name attribute carries a name created at runtime. The 'meaning' of any node is derived formally from the archetype by obtaining the text value for the archetype_node_id code from the archetype ontology section, in the language required.
Location
Data structure representing a geographical location such as a location on a map.
LocationName
Data structure capturing the name of a location
LongTermCare
A long term care encounter.
Medication
Class representing a medication. It covers the ingredients and the packaging for a medication.
MedicationAct
Base class for the act of prescribing, documenting, administering, or dispensing a medication.
MedicationDispensePerformance
Context for the documentation of a medication dispense event.
MedicationOrder
Context for a medication order.
MedicationPackage
A package for a medication.
ModifyTargetAction
Action intended to modify an existing action such as a request to discontinue the administration of a medication or a proposal to cancel an existing order. Experimental
MULTIMEDIA
A specialisation of DV_ENCAPSULATED for audiovisual and biosignal types. Includes further metadata relating to multimedia types which are not applicable to other subtypes of DV_ENCAPSULATED.
NextOfKinRelationship
Relationship to specify the next of kin relationship between two parties.
NoKnown
Context to express an assertion of absence within an open world context. Typically used for allergy and intolerance statements where the statement of no known drug allergy implies that there might be a medication the patient is allergic to but it is not known and has not been encountered at this time.
NonCompletion
A record that a clinical act was initiated by not completed.
NonPerformance
A record that a clinical act was not performed and/or never initiated. Do not use this context if the act was initiated or started but aborted or cancelled. Use the NotPerformed context instead.
Occupation
An association between a person and a kind of job that the person has held.
Order
An instruction by a healthcare provider to another healthcare provider to perform some act.
ORDERED_VALUE
Abstract class defining the concept of ordered values, which includes ordinals as well as true quantities.
ORDINAL
Models rankings and scores, e.g. pain, Apgar values, etc, where there is a) implied ordering, b) no implication that the distance between each value is constant, and c) the total number of values is finite. Note that although the term ordinal' in mathematics means natural numbers only, here any integer is allowed, since negative and zero values are often used by medical professionals for values around a neutral point. Examples of sets of ordinal values: -3, -2, -1, 0, 1, 2, 3  — reflex response values 0, 1, 2  — Apgar values This class is used for recording any clinical datum which is customarily recorded using symbolic values. Example: the results on a urinalysis strip, e.g. {neg, trace, , , } are used for leucocytes, protein, nitrites etc; for non-haemolysed blood {neg, trace, moderate}; for haemolysed blood small, moderate, large}.
Organization
An organization
OrganizationRelationship
The relationship between an actor and an organization.
OutpatientVisit
One or more encounters at one site within a specified length of time.
PackageBatch
Information about a group of medication produced or packaged from one production run.
PackageContent
A set of components that go to make up the described item.
PARSABLE
Encapsulated data expressed as a parsable String. The internal model of the data item is not described in the openEHR model in common with other encapsulated types, but in this case, the form of the data is assumed to be plaintext, rather than compressed or other types of large binary data.
Part
A component of a name or an address.
PARTICIPATION
Model of a participation of a Party (any Actor or Role) in an activity. Used to represent any participation of a Party in some activity, which is not explicitly in the model, e.g. assisting nurse. Can be used to record past or future participations. Should not be used in place of more permanent relationships between demographic entities.
PARTY
A party involved in an activity. PARTY has two specializations: ACTOR and ROLE.
PARTY_RELATIONSHIP
Association class relating two parties such as the association of an actor with one or more roles.
PartyName
Abstract supertype for the name of a party.
PartyRelationship
A relationship between two parties.
PatientEducationPerformed
Context associated with the performance of an educational intervention.
PatientRelatedEducation
This class captures information about counselling or education provided to (or an attempt to provide to) the Patient or to the Patient's representative and provides a means to note how well the Patient understood the information provided. Patient Education may be in the form of written instructions – either pre-defined materials, or personalized instructions – as well as oral counseling. In the case of pre-defined written materials, the educationalMaterialsProvided property may be used to identify the kind of material provided rather than reproducing the text of that material in this class. When personalized written instructions are provided, the text of such instructions can be placed in the textProvided property. The textProvided property may also be used to store a summary of an oral conversation with the Patient.
Performance
Context 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.
Person
Base person class.
PharmacyPromise
This class represents the prescription context from the perspective of the filling system (i.e., the pharmacy) whereas the Pharmacy Request represents the prescription from the ordering system (i.e., the prescriber). This class is a subtype of the more general Healthcare Promise, which describes properties common to all types or Orders from the filling system perspective– this class adds those properties which are specific to medication orders. This class is called Pharmacy Promise rather than Pharmacy Order following the HL7 V3 convention to use the term Promise to indicate that it is from the filling system’s perspective. There are many properties which are identical to the Order; this is because the pharmacy may change the order, within prescribed limits, for example substituting a generic drug for a brand-named one.
PhysicalEvaluationResult
Measurement resulting from a physical assessment procedure.
PLAIN_TEXT
Plain text potentially with simple formatting
Plan
Description of action that is planned to be performed. Typically, this would include a time at which the action is scheduled to be performed.
POSITIVE_INTEGER_COUNT
An integer whose value is greater than zero.
PresenceAbsenceContext
Base class for contexts asserting presence or absence of a finding.
ProcedureTopic
Description of a healthcare action, independent of action context.
Promise
An order from the perspective of a fulfillment system.
PROPORTION
Models a ratio of values, i.e. where the numerator and denominator are both pure numbers. The valid_proportion_kind property of the PROPORTION_KIND class is used to control the type attribute to be one of a defined set. Used for recording titers (e.g. 1:128), concentration ratios, e.g. Na:K (unitary denominator), albumin:creatinine ratio, and percentages, e.g. red cell distirbution width (RDW). Misuse: Should not be used to represent things like blood pressure which are often written using a '/' character, giving the misleading impression that the item is a ratio, when in fact it is a structured value. Similarly, visual acuity, often written as (e.g.) “6/24” in clinical notes is not a ratio but an ordinal (which includes non-numeric symbols like CF = count fingers etc). Should not be used for formulations.
Proposal
An offer or a suggestion to perform a healthcare act. A recommendation to a provider is an example of proposal made by a CDS system. A proposal must be accepted by an entity in order for it to be performed.
ProposalAgainst
Concept represents a recommendation from a clinical decision support system or advice from a consultation to not perform an act.
Provenance
The Provenance pattern supports the attachment of attribution information to one or more clinical statements and is not part of the clinical statements themselves. The attachment of provenance information to a clinical statement in this manner does not impact the versioning of the clinical statement target since attribution information is external to the statement.
Qualification
Education, training or special skills.
QualitativeReferenceRange
A qualitative reference range specified by a code - e.g., abnormal, severely abnormal.
QUANTIFIED
Abstract class defining the concept of true quantified values, i.e. values which are not only ordered, but which have a precise magnitude.
QuantitativeReferenceRange
A reference range specifying a quantity interval.
QUANTITY
Quantitified type representing scientific quantities, i.e. quantities expressed as a magnitude and units. Units were inspired by the Unified Code for Units of Measure (UCUM), developed by Gunther Schadow and Clement J. McDonald of The Regenstrief Institute. Can also be used for time durations, where it is more convenient to treat these as simply a number of seconds rather than days, months, years.
RATIO
A parameterizable ratio.
Real
32-bit real numbers in any interoperable representation, including single-width IEEE floating point
ReferenceRange
A reference range for the specific instance after lookup from, say, a reference range table given specific criteria. Note that this reference range is not definitional in nature but rather refers to the reference range considered for the given observation for a subject.
Referral
Used to record and send details about a request for referral service or transfer of a patient to the care of another provider or provider organization.
Registration
NEED DEFINITION
ReportableEventEntry
A reportable event may be an untoward or unexpected finding observed during the course of an activity or an activity that may result in harm to a subject and which must be documented.
Request
An request by a healthcare provider or system to another healthcare provider or system to perform some act.
ResearchStudy
Class representing a clinical trial or other research study. Class is a placeholder and will be further defined for the next ballot cycle.
Residency
Type supporting the capture of residency information.
RiskAssertion
An assertion about a risk to the patient. At this time, the class is a placeholder.
Role
A role in a participation.
SECTION
Represents a heading in a heading structure, or section tree . Can also be used to represent a collection of entries without metadata. (For collections of entries with shared metadata, use COMPOUND _ENTRY instead). Created according to archetyped structures for typical headings such as SOAP, physical examination, but also pathology result heading structures. Should not be used instead of ENTRY hierarchical structures.
ShortStay
An encounter that is similar to outpatient but the patient is admitted to a bed.
Signature
A digital signature along with supporting context. The signature may be electronic/cryptographic in nature, or a graphical image representing a hand-written signature, or a signature process. Different Signature approaches have different utilities.
SimpleComponent
A leaf-level component of a clinical statement such as a component for a complex medication that is ordered as a single unit or individual observation components associated with a wound assertion such as the diameter of a wound.
Specimen
Sample for analysis
SpecimenCollection
Attribution specific to the collection of a specimen.
SpecimenContainer
Direct container of specimen (tube/slide, etc.)
SpecimenTreatment
Treatment performed on the specimen.
StatementContext
Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
StatementTopic
Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of the statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the provenance of this information (the who, when, where, how, why of the information recorded).
Street
The name of a street.
StreetNumber
The number of a residence in a street.
String
represents unicode-enabled strings
SubjectOfInformation
The subject of information of a clinical statement.
Substance
A homogeneous material with a definite composition.
SubstanceInstance
A specific package/container of the substance.
SubstitutionBase
Base class for prospective and retrospective medication substitution information.
SubstitutionInformation
Information about a substitution that was performed.
SubstitutionInstruction
Substitution instructions for prospective dispense clinical statements.
SurgicalProcedure
A surgical procedure.
SurgicalProcedureOnDevice
Procedure for the insertion or removal of an implant.
TERM_MAPPING
Represents a coded term mapped to a TEXT, and the relative match of the target term with respect to the mapped item. Plain or coded text items may appear in the EHR for which one or mappings in alternative terminologies are required. Mappings are only used to enable computer processing, so they can only be instances of CODED_TEXT. Used for adding classification terms (e.g. adding ICD classifiers to SNOMED descriptive terms), or mapping into equivalents in other terminologies (e.g. across nursing vocabularies).
TEXT
Abstract parent for text and coded text item, which may contain any amount of legal characters arranged as e.g. words, sentences etc (i.e. one TEXT may be more than one word). Visual formatting and hyperlinks may be included.
TIME
Represents an absolute point in time from an origin usually interpreted as meaning the start of the current day, specified to a fraction of a second. Semantics defined by ISO 8601. Used for recording real world times, rather than scientifically measured fine amounts of time. The partial form is used for approximate times of events and substance administrations.
Timing
A timing schedule that specifies an event that may occur multiple times
TimingRepeat
When an event is to occur.
Transfer
The act of transferring a patient from one location or responsible organization to another. Note that a transfer from organization to another will, by definition, trigger a new encounter. Note that a transfer from one location to another may trigger a new encounter depending on whether the responsible organization has changed. A movement from one bed within the same ward to another probably will not, but a movement from one ward to another probably would.
Tunneling
whether tunneling is present
Undermining
whether undermining is present
UnitOfDistribution
Abstract class representing a substance container or package.
UNSIGNED_INTEGER_COUNT
An integer whose value is greater or equal to zero.
URI
A URI
URI_VALUE
A reference to an object which conforms to the Universal Resource Identifier (URI) standard. See 'Universal Resource Identifiers in WWW' by Tim Berners-Lee at http://www.ietf.org/rfc/rfc3986.txt. This is a World-Wide Web RFC for global identification of resources. See http://www.w3.org/Addressing for a starting point on URIs.
Use
Structure capturing usage preferences for, say, a name, an address, or contact information.
VIRTUAL_CLUSTER
A dependent model structure designed to support attribute reuse but which may be ignored by tooling such as code generators. This allows grouping of attributes to be used in a number of compositional structures in order to encourage pattern reuse and consistency but which can be structurally flattened in a derived artifact (e.g., a java class representing the composition). An example of this pattern is the CIMI Clinical Statement pattern which combines statement context and topic to build the set of relevant clinical statements.
VirtualEncounter
Services provided includes Telehealth, Web health etc.
WorkflowBreach
A workflow breach consists of an undesired event (e.g., the administration of a wrong medication), a set of possible documented outcomes (note that near misses may not have an associated outcome) and the activity that was expected to be performed as part of the workflow (e.g., the administration of the prescribed medication). Workflow breaches may be referenced by a number of different report entries.
WorkflowBreachReportEntry
An undesired activity or breach of protocol, regardless of whether it resulted in harm to the subject, which must be documented.
WoundAssertion
An assertion of a wound.
WoundBedAndEdge
Characteristics of the wound's base and its edge.
WoundDressing
Description of the dressing on a wound.
WoundExudate
Description of the exudate from a wound.
YESNO
Items which are truly boolean data, such as true/false or yes/no answers. For such data, it is important to devise the meanings (usually questions in subjective data) carefully, so that the only allowed results are in fact true or false. Misuse: The DV_BOOLEAN class should not be used as a replacement for naively modelled enumerated types such as male/female etc. Such values should be coded, and in any case the enumeration often has more than two values.
CIMI Reference Model