Description

The purpose of the Health Care Survey use case is to identify the hospital (emergency department and inpatient care) and ambulatory care data that will be extracted from EHRs and/or clinical data repositories via FHIR APIs and sent to a system hosted at the federal level. This use case will help define how EHR data can be used in automated data collection, thereby reducing burden for the healthcare provider and EHR with the goal of increasing the submission of timely, quality health care data to the National Center for Health Statistics (NCHS).

Problem Statement

The current ambulatory (manual medical record abstraction) and hospital (claims) data collection method is burdensome for providers, lacks clinical richness, and is inefficient for NCHS.

Goals of the Use Case

Increase the response rate of sampled hospitals and ambulatory health care providers to the National Hospital Care Survey (NHCS) and the National Ambulatory Medical Care Survey (NAMCS)
Increase the volume, quality, completeness, and timeliness of data submitted to the NHCS and NAMCS
Reduce the burden, including cost, associated with survey participation for hospitals, ambulatory health care providers, and data source vendors
Reduce NCHS’s costs associated with recruiting hospital and ambulatory health care providers, and the processing of NHCS and NAMCS data
Develop a complete use case that can be supported by the MedMorph Reference Architecture for the reporting of health care survey data from health care providers and systems to NCHS

Scope of the Use Case

In-Scope

Collect standardized data based on eligibility criteria from NAMCS[1] and NHCS[2] in the hospital and ambulatory care settings
Define under what circumstances a data source system must create and transmit a report to the NCHS data store
Identify the data elements to be retrieved from the data source to produce the report
Collect partial provider-level and all available patient-level data for NAMCS
Collect partial hospital/facility-level and all available patient-level data for NHCS

Out-of-Scope

Assessment of the data quality of the content extracted from the data source
Data captured outside the data source and communicated directly to registries
Changes to existing provider workflow or existing data entry
Policies of the clinical care setting to collect consent for data sharing. (Provider participation in the National Health Care Surveys is by invitation by NCHS based on being selected as part of the nationally representative samples of providers. Consent for participation in each National Health Care Survey is obtained during the manual recruitment process.)
Adult day services centers, residential care communities, nursing homes, home health agencies, and hospice
The National Hospital Ambulatory Medical Care Survey (NHAMCS) is designed to collect data on the utilization and provision of ambulatory care services in hospital emergency and outpatient departments and ambulatory surgery locations. While this IG could be used for NHAMCS data collection, at the present time NCHS is not intending to do so

Use Case Actors

Data Source: A system (e.g., EHR, clinical data repository) used in care delivery for patients which captures and stores data about patients and makes the information available instantly and securely to authorized users. While a data source does contain the medical and treatment histories of patients, a data source system is built to go beyond standard clinical data collected in a provider’s provision of care location and can be inclusive of a broader view of a patient’s care. EHRs are a vital part of health IT and can:

Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
Automate and streamline provider workflow

A FHIR Enabled Data Source exposes FHIR APIs for other systems to interact with the data source and exchange data. FHIR APIs provide well defined mechanisms to read and write data. The FHIR APIs are protected by an Authorization Server which authenticates and authorizes users or systems prior to accessing the data. The data source in this use case is a FHIR Enabled EHR.

Health Data Exchange App (HDEA) MedMorph’s backend services app: A system that resides within the clinical care setting and performs the reporting functions to public health and/or research registries. The system uses the information supplied by the NCHS to determine when reporting needs to be done, what data needs to be reported, how the data needs to be reported, and to whom the data should be reported. The term “backend service” is used to refer to the fact that the system does not require user intervention to perform reporting. The term “app” is used to indicate that it is similar to a SMART on FHIR App which can be distributed to clinical care via the EHR specified processes. The EHR specified processes are followed to enable the Backend Services App to use the EHR's FHIR APIs to access data. The hospital or ambulatory organization is the one who is responsible for choosing and maintaining the HDEA.

National Center for Health Statistics (NCHS) Data Store: A FHIR server or service that receives and stores the health care survey data.

Health Care Survey Process Abstract Model

Figure 1 below is the high-level model that illustrates the actors, activity, and systems involved in Health Care Survey workflow.

Figure 1: Health Care Survey Abstract Model

The FHIR Enabled Data Source sends subscription notifications to the HDEA when there has been activity in topics to which the app subscribes. The HDEA then queries the Data Source for survey data and the Data Source returns the appropriate FHIR resources. The HDEA receives and validates the resources. The resources are compiled into a FHIR bundle and sent to the NCHS Data Store.

Use Case User Stories and Diagrams

Preconditions

Preconditions describe the state of the system, from a technical perspective, that must be true before an operation, process, activity, or task can be executed. Preconditions are what needs to be in place before executing the use case flow.

The preconditions for the healthcare survey reporting use case include:

Use Case Trigger: A patient encounter has happened, and the provider has signed off on the encounter
The data source, provider, and receiving systems expose HL7 FHIR APIs
Pertinent data elements are captured discretely in the data source
Public Health uses allowed by HIPAA and other statutory authorities have been defined and implemented
Provisioning workflows have been established. The provisioning workflow includes activities that publish the various metadata artifacts required to make data source data available to public health and/or research. These activities include publishing value sets, trigger codes, reporting timing parameters, survey instruments, structures for reporting, etc. These artifacts are used subsequently in data collection and reporting workflows
NCHS is authorized to collect hospital and other healthcare entities data under the authority of section 306 of the Public Health Service Act (42 United States Code 242k)
Participant has volunteered to participate in a National Health Care Survey (including data agreements if applicable)
Physician:
- was sampled by NCHS and voluntarily recruited
- has a partner who was sampled last year, underwent system testing and validation, and moved onto production submission of data
- has already completed the provider level data collection for the survey year (however, this will not preclude confirmative and supplementary data collection of provider-level data from the FHIR Provider resource, as well as potentially other FHIR resources that can provide provider-level data during the patient-level data collection)

User Stories

User Story 1 – Ambulatory Setting

Background: The National Ambulatory Medical Care Survey (NAMCS) is based on a sample of patient visits to non-federally employed office-based physicians (primary care or specialist) who are primarily engaged in direct patient care. Starting in 2006, a separate sample of visits to community health centers (CHC) was added; in 2021, the former CHC sample of NAMCS was redesigned and launched as the health center (HC) component. NAMCS collects an encounter-based set of demographic and clinical data generally available in a medical record for any type of visit.

Workflow: Upon completion of an encounter, the physician or licensed clinician, using the EHR, completes and closes the clinical encounter (“sign off”). This “sign off” triggers the Health Data Exchange App (HDEA), MedMorph’s backend services app, to evaluate the completed encounter. The completed encounter evaluation by the HDEA includes validating that the provider associated with the encounter is a “sampled” NAMCS provider and the encounter occurred within a specified timeframe. If the encounter meets the criteria, and after a lag period to allow for lab results to post when applicable, the HDEA requests a set of FHIR resources representing patient-level and select provider-level data of the encounter from the Data Source. The obtained resources are validated (e.g., conformant to the appropriate FHIR profiles) and transmitted to NCHS where they are received, acknowledged, and loaded into the NCHS Data Store.

The table below illustrates each actor, role, activity, input, and output of each step of the Health Care Survey Ambulatory workflow.

Table 1: HCS Ambulatory Setting Workflow

Step	Actor	Role	Activity	Input(s)	Output(s)

Step	Actor	Role	Activity	Input(s)	Output(s)
1	Data Source	Notifier	Notify the HDEA that a trigger event has occurred	Trigger codes	Notification message (e.g., “completed encounter” event) for a topic
2	HDEA	Evaluator	Evaluate notification message against criteria	Notification message content	Continuation decision based on available information
3	HDEA	Data Extractor	Query the Data Source for provider information	Query decision	FHIR query
4	Data Source	Query Responder	Return provider data	FHIR query	FHIR Provider Resource
5	HDEA	Evaluator	Evaluate provider information, notification message	FHIR Provider Resource, Notification message	Submittal decision based on available information
6	HDEA	Data Extractor	Query the Data Source for survey data	Notification message, timing, and other criteria	FHIR query
7	Data Source	Query Responder	Return survey data	FHIR query	FHIR resources
8	HDEA	Data Receiver	Receive FHIR resources and validate FHIR bundle	FHIR resources	FHIR validated Bundle
9	HDEA	Data Sender	Send validated FHIR bundle to NCHS Data Store	FHIR validated Bundle	FHIR validated Bundle
10	NCHS Data Store	Data Receiver	Receive and validate FHIR bundle	FHIR bundle	Validated FHIR bundle

User Story 1 – Ambulatory Setting Activity Diagram

Figure 2 below illustrates the flow of events and information between the actors for the Health Care Survey Ambulatory workflow.

Figure 2: HCS Ambulatory User Story Activity Diagram

User Story 1 – Ambulatory Setting Sequence Diagram

Figure 3 below represents the interactions between actors in the sequential order that they occur in the Health Care Survey Ambulatory workflow.

Figure 3: HCS Ambulatory User Story Sequence Diagram

User Story 2 – Hospital Setting

Background: The National Hospital Care Survey (NHCS) is an electronic data collection, gathering Uniform Bill (UB) 04 administrative claims data or electronic health record data from sampled hospitals. NHCS is designed to provide reliable and timely nationally representative healthcare utilization data for hospital-based settings. NHCS collects all inpatient discharges, and Emergency Department (ED) encounters from sampled hospitals for a survey period of one year. NHCS’ sample is drawn from all non-federal US hospitals with a bed size > 6.

Workflow: Upon completion of an inpatient or ED encounter, the physician or licensed clinician completes and closes the clinical encounter (“sign off”). This “sign off” triggers the HDEA to evaluate the completed encounter against the NHCS criteria. If the encounter meets the survey criteria, and after a lag period to allow for lab results to post when applicable, the HDEA requests a set of FHIR resources representing patient-level and select provider-level data of the encounter from the Data Source. Once obtained and validated, these resources are transmitted to NCHS where they are received, acknowledged, validated, and loaded into the NCHS Data Store.

The table below illustrates each actor, role, activity, input, and output of each step of the Health Care Survey Hospital Setting workflow.

Table 2: HCS Hospital Setting Workflow

Step	Actor	Role	Activity	Input(s)	Output(s)
1	Data Source	Notifier	Notify the HDEA that a trigger event has occurred been met	Data or workflow trigger	Notification message (e.g., “completed encounter” event as a topic)
2	HDEA	Evaluator	Evaluates notification message against criteria	Notification message content	Continuation decision based on available information
3	HDEA	Data Extractor	Query the Data Source System for survey data	Notification message, timing, and other criteria	FHIR query
4	Data Source	Query Responder	Return survey data	FHIR query	FHIR resources
5	HDEA	Data Receiver	Receive FHIR resources and validate FHIR bundle	FHIR resources	FHIR validated bundle
6	HDEA	Data Sender	Send validated FHIR bundle to NCHS Data Store	FHIR validated bundle	FHIR validated bundle
7	NCHS Data Store	Data Receiver	Receive and validate FHIR bundle	FHIR bundle	Validated FHIR bundle

User Story 2 – Hospital Setting Activity Diagram

Figure 4 below illustrates the flow of events and information between the actors for the Health Care Survey Hospital Setting workflow.

Figure 4: HCS Hospital Setting User Story Activity Diagram

User Story 2 – Hospital Setting Sequence Diagram

Figure 5 below represents the interactions between actors in the sequential order that they occur in the Health Care Survey Hospital Setting workflow.

Figure 5: HCS Hospital Setting User Story Sequence Diagram

Postconditions

A completed survey resides in the National Center for Health Statistics Data Store.

Alternate Flow

None

Data Requirements

The table below includes the data requirements for the Health Care Survey use case based on the abstract model and use case flows.

Click here for a detailed Excel version of the data requirements that includes mock data.

Table 3. Health Care Survey Data Elements

Health Care Surveys Data Element	Definition (unless otherwise Noted, this is the FHIR Resource definition)	USCDI V1 Data Class	USCDI V1 Data Element	US Core Profile or FHIR Base Resource	FHIR Resource.element	Flag**	Setting			Value Set (when applicable)	Value Set Example(s)***
Health Care Surveys Data Element		USCDI V1 Data Class	USCDI V1 Data Element	US Core Profile or FHIR Base Resource	FHIR Resource.element	Flag**	ED	IP	OP	Value Set (when applicable)	Value Set Example(s)***
Patient Information
Patient given name	Given name. (Given names (not always 'first'). Includes middle names).	Patient Demographics	First Name	US Core Patient Profile	Patient.name.given	M	x	x	x	N/A	N/A
Patient family name	The part of a name that links to the genealogy. In some cultures (e.g. Eritrea) the family name of a son is the first name of his father.	Patient Demographics	Last Name	US Core Patient Profile	Patient.name.family	M	x	x	x	N/A	N/A
Patient previous name	NOTE: Patient's previous name. (optional)	Patient Demographics	Previous name	US Core Patient Profile	Patient.name	M	x	x	x	N/A	N/A
Patient name suffix	Part of the name that is acquired as a title due to academic, legal, employment or nobility status, etc. and that appears at the end of the name.	Patient Demographics	Suffix	US Core Patient Profile	Patient.name.suffix	0	x	x	x	N/A	N/A
Patient birth sex	Codes for assigning sex at birth as specified by the Office of the National Coordinator for Health IT (ONC)	Patient Demographics	Birth Sex	US Core Patient Profile	Patient.extension:us-core-birthsex	M	x	x	x	http://hl7.org/fhir/us/core/ValueSet/us-core-birthsex	Unknown
Patient date of birth	The date of birth for the individual.	Patient Demographics	Date of Birth	US Core Patient Profile	Patient.birthDate	S	x	x	x	N/A	N/A
Patient race	Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the CDC Race and Ethnicity Code Set Version 1.0 which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories: American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or Other Pacific Islander; White.	Patient Demographics	Race	US Core Patient Profile	Patient.extension:us-core-race	S	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-omb-race-category.html ; https://www.hl7.org/fhir/us/core/ValueSet-detailed-race.html
Patient ethnicity	Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The ethnicity codes used to represent these concepts are based upon the CDC ethnicity and Ethnicity Code Set Version 1.0 which includes over 900 concepts for representing race and ethnicity of which 43 reference ethnicity. The ethnicity concepts are grouped by and pre-mapped to the 2 OMB ethnicity categories: - Hispanic or Latino - Not Hispanic or Latino.	Patient Demographics	Ethnicity	US Core Patient Profile	Patient.extension:us-core-ethnicity	S	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-omb-ethnicity-category.html ; https://www.hl7.org/fhir/us/core/ValueSet-detailed-ethnicity.html
Patient preferred language	A language which may be used to communicate with the patient about his or her health.	Patient Demographics	Preferred Language	US Core Patient Profile	Patient.communication	S	x	x	x
Patient Address(es) Line	Street address.	Patient Demographics	Address	US Core Patient Profile	Patient.address.line	S	x	x	x
Patient Address(es) City	Address city.	Patient Demographics	Address	US Core Patient Profile	Patient.address.city	S	x	x	x
Patient Address(es) State	Address state.	Patient Demographics	Address	US Core Patient Profile	Patient.address.state	S	x	x	x
Patient Address(es) Postal Code	Address postal code.	Patient Demographics	Address	US Core Patient Profile	Patient.address.postalCode	S	x	x	x
Patient Address(es) Period	Time period when address was/is in use.	Patient Demographics	Address	US Core Patient Profile	Patient.address.period	S	x	x	x
Patient Phone Number	A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted.	Patient Demographics	Phone Number	US Core Patient Profile	Patient.telecom.value	S	x	x	x
Patient Contact Type	Telecommunications form for contact point - what communications system is required to make use of the contact.	Patient Demographics	Phone Number	US Core Patient Profile	Patient.telecom.system=phone	S	x	x	x
Patient Phone Number type	Identifies the purpose for the contact point.	Patient Demographics	Phone Number type	US Core Patient Profile	Patient.telecom.use	S	x	x	x	http://hl7.org/fhir/ValueSet/contact-point-use	mobile
Patient Email address	A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted.	Patient Demographics	Email Address	US Core Patient Profile	Patient.telecom.value	S	x	x	x
Patient Contact Type	Telecommunications form for contact point - what communications system is required to make use of the contact.	Patient Demographics	Email Address	US Core Patient Profile	Patient.telecom.system=email	S	x	x	x
Patient Email address type	Identifies the purpose for the contact point.	Patient Demographics	Email address type	US Core Patient Profile	Patient.telecom.use	S	x	x	x
Patient Medicare number	The Medicare number for this patient.			US Core Patient Profile	Patient.identifier.value	M	x	x	x
Patient Identifier Type	A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.			US Core Patient Profile	Patient.identifier.type=SB	S
Patient's medical record number	The namespace for the identifier value			US Core Patient Profile	Patient.identifier.value	M	x	x	x
Patient Identifier System	The namespace for the identifier value			US Core Patient Profile	Patient.identifier.system	S	x	x
Patient's social security number	The medical record number for this patient.	Patient Demographics	Social Security Number/Level 1	US Core Patient Profile	Patient.identifier.value	S	1..1	x	x	x
Patient Identifier System	The namespace for the identifier value		Patient idnetifier type	US Core Patient Profile	Patient.identifier.system	S	1..1	x	x	x
Patient Primary Care Provider	Patient's nominated care provider.			US Core Patient Profile	Patient.generalPractitioner	0			x
Smoking Status
Patient Smoking status	This profile sets minimum expectations for the Observation resource to record, search, and fetch smoking status data associated with a patient.	Smoking Status	Smoking Status	US Core Smoking Status Observation Profile	Observation.valueCodeableConcept.code	S	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-observation-smokingstatus.html
Care Team Members
Member(s) involved in Care Team	Identifies all people and organizations who are expected to be involved in the care team.	Care Team Member(s)	Care Team Member(s)	US Core CareTeam Profile	CareTeam.participant	M	x	x	x
Care Team Member Role	Indicates specific responsibility of an individual within the care team, such as "Primary care physician", "Trained social worker counselor", "Caregiver", etc.	Care Team Member(s)	Care Team Member(s)	US Core CareTeam Profile	CareTeam.participant.role	M	x	x	x	https://build.fhir.org/ig/HL7/US-Core-R4/ValueSet-us-core-careteam-provider-roles.html	Emergency Medical Service Providers
Care Team Member	The specific person or organization who is participating/expected to participate in the care team.	Care Team Member(s)	Care Team Member(s)	US Core CareTeam Profile	CareTeam.participant.member	M	x	x	x	Reference(US Core Patient Profile \| US Core Practitioner Profile \| US Core Organization Profile)	US Core Practitioner
Care Team Member Status	Indicates the current state of the care team.	Care Team Member(s)	Care Team Member(s)	US Core CareTeam Profile	CareTeam.status	S	x	x	x	http://hl7.org/fhir/ValueSet/care-team-status	Active
Care Team Member Patient	Who care team is for			US Core CareTeam Profile	CareTeam.subject	S	1…1
Provider NPI		Care Team Member(s)	Care Team Member Identifier/ V2	US Core CareTeam Profile	CareTeam.participant.member.practitioner.identifier:NPI	S	0..1	x		x














Encounter Information
Encounter status	Current state of the encounter.			US Core Encounter Profile	Encounter.status	M	x	x	x	http://hl7.org/fhir/ValueSet/encounter-status	planned \| arrived \| triaged \| in-progress \| onleave \| finished \| cancelled +.
Classification of Pt, Encounter	Concepts representing classification of patient encounter such as ambulatory (outpatient), inpatient, emergency, home health or others due to local variations.			US Core Encounter Profile	Encounter.class	M	x	x	x	http://hl7.org/fhir/ValueSet/v3-ActEncounterCode	inpatient \| outpatient \| ambulatory \| emergency +.
Encounter type	Specific type of encounter (e.g. e-mail consultation, surgical day-care, skilled nursing, rehabilitation). NOTE: This is constrained to E&M codes.			US Core Encounter Profile	Encounter.type	M	X	x	X	http://www.ama-assn.org/go/cpt	99201: Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making.
Encounter subject	The patient or group present at the encounter.			US Core Encounter Profile	Encounter.subject	M	x	x	x
Encounter Identifier	Identifier(s) by which this encounter is known.			US Core Encounter Profile	Encounter.identifier.value	S	x	x	x
Encounter period	The start and end times of the encounter.			US Core Encounter Profile	Encounter.period	S	x	x	x
Encounter participant individual	Persons involved in the encounter other than the patient. Reference(US Core Practitioner Profile)			US Core Encounter Profile	Encounter.participant.individual	S	x	x	x	Reference(US Core Practitioner Profile)
Encounter participant type	Role of participant in encounter.			US Core Encounter Profile	Encounter.participant.type	S	x	x	x	http://hl7.org/fhir/ValueSet/encounter-participant-type	consultant - An advisor participating in the service by performing evaluations and making recommendations.
Primary participant responsible for encounter	Encounter primary performer of service.			US Core Encounter Profile	Encounter.participant.type=PPRF	S	x	x	x	http://hl7.org/fhir/ValueSet/encounter-participant-type
Participant overseeing the encounter	Participant overseeing the encounter			US Core Encounter Profile	Encounter.participant.type=ATND	S	x	x	x	http://hl7.org/fhir/ValueSet/encounter-participant-type
Encounter primary performer NPI	NPI of encounter primary performer.			US Core Encounter Profile	Encounter.participant.individual.Practitioner.identifier:NPI	0	x	x	x
Encounter primary performer name	Name of encounter primary performer.			US Core Encounter Profile	Encounter.participant.individual.Practitioner.NAME	0	x	x	x
Time period participant participated in the encounter	The period of time that the specified participant participated in the encounter. These can overlap or be sub-sets of the overall encounter's period.			US Core Encounter Profile	Encounter.participant.period	S	x	x	x
Reason for the visit	Reason the encounter takes place, expressed as a code.			US Core Encounter Profile	Encounter.reasonCode	S	x	x	x	http://hl7.org/fhir/ValueSet/encounter-reason
Diagnoses relevant to this encounter	The list of diagnosis relevant to this encounter.			Encounter	Encounter.diagnosis.condition	0	x	x	x	Reference(Condition \| Procedure)
Encounter primary diagnosis	Reason the encounter takes place, as specified using information from another resource. For admissions, this is the admission diagnosis. The indication will typically be a Condition (with other resources referenced in the evidence.detail), or a Procedure. "For systems that need to know which was the primary diagnosis, these will be marked with the standard extension primaryDiagnosis (which is a sequence value rather than a flag, 1 = primary diagnosis)."			Encounter	Encounter.diagnosis.condition extension primaryDiagnosis	0	x	x	x
Encounter principal diagnosis	NOTE: The principal diagnosis is the "condition established after study to be chiefly responsible for occasioning the admission of the patient …" (Source: ICD-10-CM Official Guidelines for Coding and Reporting, FY2019, pp. 107). All institutional claims require a principal diagnosis whether they are inpatient or outpatient facilities.			Encounter	Encounter.diagnosis.rank=1 when diagnosis.use=billing	0	x	x	x
Hospital encounter discharge disposition	Category or kind of location after discharge.			US Core Encounter Profile	Encounter.hospitalization.dischargeDisposition	S	x	x		http://hl7.org/fhir/ValueSet/encounter-discharge-disposition
Encounter location address	The location where the encounter takes place.			US Core Encounter Profile	Encounter.location.location.address	M	x	x	x
Expected source(s) of payment for this encounter	The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.			Encounter	Encounter.account.coverage.type	0	x	x	x	http://hl7.org/fhir/R4/valueset-coverage-type.html
Encounter chief complaint	Role that this diagnosis has within the encounter (e.g. chief complaint).			Encounter	Encounter.diagnosis.use = CC	0	x	x	x	http://hl7.org/fhir/R4/valueset-diagnosis-role.html	CC
Clinical Notes
Consultation Note identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
Consultation Note status	The status of this document reference.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
Consultation Note type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.type=11488-4	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	11488-4 http://loinc.org Consult note
Consultation Note category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
Consultation Note date	When the document reference was created.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
Consultation Note Patient	Who/what is the subject of the document			US Core DocumentReference Profile	DocumentReference.subject	M	x	x	x
Consultation Note author	Who and/or what authored the document	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
Consultation Note custodian	Organization which maintains the document	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
Consultation Note content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
Consultation Note content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
Consultation Note content url	A location where the data can be accessed.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
Consultation Note content format	Format/content rules for the document	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
Consultation Note encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
Consultation Note period	The time period over which the service that is described by the document was provided.	Clinical Notes	Consultation Note	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
Discharge Summary Note identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
Discharge Summary Note status	The status of this document reference.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
Discharge Summary Note type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.type=18842-5	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	18842-5 http://loinc.org Discharge summary
Discharge Summary Note category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
Discharge Summary Note date	When the document reference was created.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
Discharge Summary Patient	Who/what is the subject of the document			US Core DocumentReference Profile	DocumentReference.subject	M	x	x	x
Discharge Summary Note author	Who and/or what authored the document	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
Discharge Summary Note custodian	Organization which maintains the document	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
Discharge Summary Note content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
Discharge Summary Note content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
Discharge Summary Note content url	A location where the data can be accessed.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
Discharge Summary Note content format	Format/content rules for the document	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
Discharge Summary Note encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
Discharge Summary Note period	The time period over which the service that is described by the document was provided.	Clinical Notes	Discharge Summary Note	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
History & Physical identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
History & Physical status	The status of this document reference.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
History & Physical type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.type=34117-2	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	34117-2 http://loinc.org History and physical note
History & Physical category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
History & Physical date	When the document reference was created.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
History & Physical Patient	Who/what is the subject of the document			US Core DocumentReference Profile	DocumentReference.subject	M	x	x	x
History & Physical author	Who and/or what authored the document	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
History & Physical custodian	Organization which maintains the document	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
History & Physical content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
History & Physical content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
History & Physical content url	A location where the data can be accessed.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
History & Physical content format	Format/content rules for the document	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
History & Physical encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
History & Physical period	The time period over which the service that is described by the document was provided.	Clinical Notes	History & Physical	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
Imaging Narrative identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
Imaging Narrative status	The status of this document reference.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
Imaging Narrative type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.type=LP29684-5	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	LP29684-5 http://loinc.org Radiology
Imaging Narrative category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
Imaging Narrative date	When the document reference was created.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
Imaging Narrative author	Who and/or what authored the document	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
Imaging Narrative custodian	Organization which maintains the document	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
Imaging Narrative content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
Imaging Narrative content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
Imaging Narrative content url	A location where the data can be accessed.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
Imaging Narrative content format	Format/content rules for the document	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
Imaging Narrative encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
Imaging Narrative period	The time period over which the service that is described by the document was provided.	Clinical Notes	Imaging Narrative	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
Imaging Narrative Diagnostic Report status	The status of the diagnostic report.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-diagnostic-report-status.html	registered \| partial \| preliminary \| final +
Imaging Narrative Diagnostic Report category	A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.category	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-category.html	LP29684-5 Radiology LP29708-2 Cardiology LP7839-6 Pathology
Imaging Narrative Diagnostic Report code	The test, panel, report, or note that was ordered.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.code	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-report-and-note-codes.html
Imaging Narrative Diagnostic Report Subject	The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.			US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.subject	M	x	x	x
Imaging Narrative Diagnostic Report encounter	The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.encounter	S	x	x	x	Reference(US Core Encounter Profile)
Imaging Narrative Diagnostic Report effective	This is the Datetime or Period when the report or note was written.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.effective[x]	M	x	x	x
Imaging Narrative Diagnostic Report issued	The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.issued	S	x	x	x
Imaging Narrative Diagnostic Report performer	The diagnostic service that is responsible for issuing the report.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.performer	S	x	x	x
Imaging Narrative Diagnostic Report presented form	Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.	Clinical Notes	Imaging Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.presentedForm	S	x	x	x
Laboratory Report Narrative identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
Laboratory Report Narrative status	The status of this document reference.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
Laboratory Report Narrative type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.type=11502-2	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	11502-2 http://loinc.org Laboratory Report
Laboratory Report Narrative category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
Laboratory Report Narrative date	When the document reference was created.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
Laboratory Report Narrative Patient	Who/what is the subject of the document			US Core DocumentReference Profile	DocumentReference.subject	M	x	x	x
Laboratory Report Narrative author	Who and/or what authored the document	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
Laboratory Report Narrative custodian	Organization which maintains the document	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
Laboratory Report Narrative content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
Laboratory Report Narrative content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
Laboratory Report Narrative content url	A location where the data can be accessed.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
Laboratory Report Narrative content format	Format/content rules for the document	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
Laboratory Report Narrative encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
Laboratory Report Narrative period	The time period over which the service that is described by the document was provided.	Clinical Notes	Laboratory Report Narrative	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
Laboratory Report Narrative Diagnostic Report status	The status of the diagnostic report.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-diagnostic-report-status.html	registered \| partial \| preliminary \| final +
Laboratory Report Narrative Diagnostic Report category	A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.category	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-category.html	LP29684-5 Radiology LP29708-2 Cardiology LP7839-6 Pathology
Laboratory Report Narrative Diagnostic Report code	The test, panel, report, or note that was ordered.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.code	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-report-and-note-codes.html
Laboratory Report Narrative Diagnostic Report Subject	The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.			US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.subject	M	x	x	x
Laboratory Report Narrative Diagnostic Report encounter	The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.encounter	S	x	x	x	Reference(US Core Encounter Profile)
Laboratory Report Narrative Diagnostic Report effective	This is the Datetime or Period when the report or note was written.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.effective[x]	M	x	x	x
Laboratory Report Narrative Diagnostic Report issued	The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.issued	S	x	x	x
Laboratory Report Narrative Diagnostic Report performer	The diagnostic service that is responsible for issuing the report.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.performer	S	x	x	x
Laboratory Report Narrative Diagnostic Report presented form	Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.	Clinical Notes	Laboratory Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.presentedForm	S	x	x	x
Pathology Report Narrative identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
Pathology Report Narrative status	The status of this document reference.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
Pathology Report Narrative type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.type=LP7839-6	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	LP7839-6 http://loinc.org Pathology
Pathology Report Narrative category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
Pathology Report Narrative date	When the document reference was created.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
Pathology Report Narrative Patient	Who/what is the subject of the document			US Core DocumentReference Profile	DocumentReference.subject	M	x	x	x
Pathology Report Narrative author	Who and/or what authored the document	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
Pathology Report Narrative custodian	Organization which maintains the document	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
Pathology Report Narrative content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
Pathology Report Narrative content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
Pathology Report Narrative content url	A location where the data can be accessed.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
Pathology Report Narrative content format	Format/content rules for the document	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
Pathology Report Narrative encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
Pathology Report Narrative period	The time period over which the service that is described by the document was provided.	Clinical Notes	Pathology Report Narrative	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
Pathology Report Narrative status	The status of the diagnostic report.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-diagnostic-report-status.html	registered \| partial \| preliminary \| final +
Pathology Report Narrative category	A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.category	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-category.html	LP29684-5 Radiology LP29708-2 Cardiology LP7839-6 Pathology
Pathology Report Narrative code	The test, panel, report, or note that was ordered.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.code	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-report-and-note-codes.html
Pathology Report Narrative encounter	The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.encounter	S	x	x	x	Reference(US Core Encounter Profile)
Pathology Report Narrative effective	This is the Datetime or Period when the report or note was written.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.effective[x]	M	x	x	x
Pathology Report Narrative issued	The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.issued	S	x	x	x
Pathology Report Narrative performer	The diagnostic service that is responsible for issuing the report.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.performer	S	x	x	x
Pathology Report Narrative presented form	Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.	Clinical Notes	Pathology Report Narrative	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.presentedForm	S	x	x	x
Procedure Note identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
Procedure Note status	The status of this document reference.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
Procedure Note type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.type=28570-0	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	28570-0 http://loinc.org Procedure note
Procedure Note category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
Procedure Note date	When the document reference was created.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
Procedure Note Patient	Who/what is the subject of the document			US Core DocumentReference Profile	DocumentReference.subject	M	x	x	x
Procedure Note author	Who and/or what authored the document	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
Procedure Note custodian	Organization which maintains the document	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
Procedure Note content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
Procedure Note content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
Procedure Note content url	A location where the data can be accessed.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
Procedure Note content format	Format/content rules for the document	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
Procedure Note encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
Procedure Note period	The time period over which the service that is described by the document was provided.	Clinical Notes	Procedure Note	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
Procedure Note Diagnostic Report status	The status of the diagnostic report.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-diagnostic-report-status.html	registered \| partial \| preliminary \| final +
Procedure Note Diagnostic Report category	A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.category	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-category.html	LP29684-5 Radiology LP29708-2 Cardiology LP7839-6 Pathology
Procedure Note Diagnostic Report code	The test, panel, report, or note that was ordered.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.code	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-report-and-note-codes.html
Procedure Note Diagnostic Report Subject	The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.			US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.subject	M	x	x	x
Procedure Note Diagnostic Report encounter	The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.encounter	S	x	x	x	Reference(US Core Encounter Profile)
Procedure Note Diagnostic Report effective[x]	This is the Datetime or Period when the report or note was written.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.effective[x]	M	x	x	x
Procedure Note Diagnostic Report issued	The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.issued	S	x	x	x
Procedure Note Diagnostic Report performer	The diagnostic service that is responsible for issuing the report.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.performer	S	x	x	x
Procedure Note Diagnostic Report presented form	Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.	Clinical Notes	Procedure Note	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.presentedForm	S	x	x	x
Progress Note identifier	Other identifiers associated with the document, including version independent identifiers.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.identifier	S	x	x	x
Progress Note status	The status of this document reference.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.status	M	x	x	x	http://hl7.org/fhir/R4/valueset-document-reference-status.html	current \| superseded \| entered-in-error
Progress Note type	Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.type=11506-3	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-type.html	11506-3 http://loinc.org Progress note
Progress Note category	A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.category=clinical-note	M	x	x	x	https://www.hl7.org/fhir/us/core/ValueSet-us-core-documentreference-category.html	clinical-note
Progress Note date	When the document reference was created.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.date	S	x	x	x
Progress Note Patient	Who/what is the subject of the document			US Core DocumentReference Profile	DocumentReference.subject	M	x	x	x
Progress Note author	Who and/or what authored the document	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.author	S	x	x	x	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)
Progress Note custodian	Organization which maintains the document	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.custodian	S	x	x	x	Reference(US Core Organization Profile)
Progress Note content type	Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.content.attachment.contentType	M	x	x	x
Progress Note content data	The actual data of the attachment - a sequence of bytes, base64 encoded.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.content.attachment.data	S	x	x	x
Progress Note content url	A location where the data can be accessed.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.content.attachment.url	S	x	x	x
Progress Note content format	Format/content rules for the document	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.content.format	S	x	x	x
Progress Note encounter	Describes the clinical encounter or type of care that the document content is associated with.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.context.encounter	S	x	x	x	Reference(USCoreEncounterProfile)
Progress Note period	The time period over which the service that is described by the document was provided.	Clinical Notes	Progress Note	US Core DocumentReference Profile	DocumentReference.context.period	S	x	x	x
Problems/ Health Concerns
Patient Problem/ Health Concern category	A category assigned to the condition.	Problems/ Health Concerns	Problems/ Health Concerns	US Core Condition Profile	Condition.category	M	x	x	x	http://hl7.org/fhir/us/core/ValueSet-us-core-condition-category.html	Problem List Item; encounter diagnosis; health concern
Patient Problem/ Health verification	The verification status to support the clinical status of the condition.	Problems/ Health Concerns	Problems/ Health Concerns	US Core Condition Profile	Condition.verificationStatus	S	x	x	x	http://hl7.org/fhir/ValueSet/condition-ver-status
Patient Problem/ Health Concern code	Identification of the condition, problem or diagnosis.	Problems/ Health Concerns	Problems/ Health Concerns	US Core Condition Profile	Condition.code	M	x	x	x	http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Patient Problem/ Health Concern status	The clinical status of the condition.. (e.g. active, inactive, etc..)	Problems/ Health Concerns	Problems/ Health Concerns	US Core Condition Profile	Condition.clinicalStatus	S	x	x	x	http://hl7.org/fhir/ValueSet/condition-clinical
Patient Problem/ Health Concern Onset	Estimated or actual date or date-time the condition began, in the opinion of the clinician.	Problems/ Health Concerns	Problems/ Health Concerns	Condition	condition.onset[x]	0	x	x	x
Patient Problem/ Health Concern Abatement	The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.	Problems/ Health Concerns	Problems/ Health Concerns	Condition	condition.abatement[x]	0	x	x	x
Patient Problem/ Health Concern recorded date	The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.	Problems/ Health Concerns	Problems/ Health Concerns	Condition	condition.recordedDate	0	x	x	x
Patient Problem/ Health Concern patient	Indicates the patient or group who the condition record is associated with.			US Core Condition Profile	Condition.subject	M	x	x	x
Lab Tests Ordered & Resulted
Type of observation = Laboratory	A code that classifies the general type of observation being made. "The codes SHOULD be taken from ObservationCategoryCodes", but it must have a fixed value of laboratory.	Laboratory	Tests	US Core Laboratory Result Observation Profile	Observation.category:Laboratory	M	x	x	x
Status of Lab Test Result	The status of the result value.	Laboratory	Tests	US Core Laboratory Result Observation Profile	Observation.status	M	x	x	x	http://hl7.org/fhir/ValueSet/observation-status
Lab Test code (LOINC if available)	The test that was performed. A LOINC SHALL be used if the concept is present in LOINC.	Laboratory	Tests	US Core Laboratory Result Observation Profile	Observation.code	M	x	x	x	http://hl7.org/fhir/ValueSet/observation-codes
Lab Patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.			US Core Observation Lab Profile	Observation.subject	M			x
Specimen collection or 'Ask at Order Entry' date	For lab tests this is the specimen collection date. For Ask at Order Entry Questions (AOE)'s this is the date the question was asked.	Laboratory	Tests	US Core Laboratory Result Observation Profile	Observation.effective[x]	S	x	x	x
Lab Result Value	The Laboratory result value. If a coded value, the valueCodeableConcept.code SHOULD be selected from SNOMED CT. If a numeric value, valueQuantity.code SHALL be selected from UCUM. A FHIR UCUM Codes value set that defines all UCUM codes is in the FHIR specification.	Laboratory	Values/Results	US Core Laboratory Result Observation Profile	Observation.value	S	x	x	x
Lab Result Date/Time	A date, date-time or partial date of a laboratory result generated.	Laboratory	Values/Results	US Core Laboratory Result Observation Profile	Observation.valueDateTime	S	x	c	c
Interpretation	A categorical assessment of an observation value. For example, high, low, normal.			US Core Observation Lab Profile	Observation.interpretation	O			x
Reference Range	Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two referenceRange elements would be used.			US Core Observation Lab Profile	Observation.referenceRange	O			x
Lab reason missing	Provides a reason why the expected value in the element Observation.value[x] is missing.	Laboratory	Values/Results	US Core Laboratory Result Observation Profile	Observation.dataAbsentReason	S	x	x	x	http://hl7.org/fhir/ValueSet/data-absent-reason
Diagnostic report status	The status of the diagnostic report.	Laboratory	Values/Results	US Core DiagnosticReport Profile for Laboratory Results Reporting	DiagnosticReport.status	M	x	x	x	http://hl7.org/fhir/ValueSet/diagnostic-report-status	amended
Diagnostic report category	A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.	Laboratory	Values/Results	US Core DiagnosticReport Profile for Laboratory Results Reporting	DiagnosticReport.category	M	x	x	x	http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category	pathology
Diagnostic report code	The test, panel, report, or note that was ordered.	Laboratory	Values/Results	US Core DiagnosticReport Profile for Laboratory Results Reporting	DiagnosticReport.code	M	x	x	x
Diagnostic report date/time written	This is the Datetime or Period when the report or note was written.	Laboratory	Values/Results	US Core DiagnosticReport Profile for Laboratory Results Reporting	DiagnosticReport.effective[x]	M	x	x	x
Date/time report available to providers	The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. (Example - Pathology report including a pathologist's diagnosis.)	Laboratory	Values/Results	US Core DiagnosticReport Profile for Laboratory Results Reporting	DiagnosticReport.issued	M	x	x	x
Diagnostic report performer	The diagnostic service that is responsible for issuing the report.	Laboratory	Values/Results	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.performer	S	x	x	x
Diagnostic report result	Observations that are part of this diagnostic report.	Laboratory	Values/Results	US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.result	S	x	x	x
Diagnostic report Subject	The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.			US Core DiagnosticReport Profile for Report and Note exchange	DiagnosticReport.subject	M			x
Procedures
Procedure Status	A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.	Procedures	Procedures	US Core Procedure Profile	Procedure.status	M	x	x	x
Procedure Code	The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").	Procedures	Procedures	US Core Procedure Profile	Procedure.code	M	x	x	x	http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure Performed Date/time	Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.	Procedures	Procedures	US Core Procedure Profile	Procedure.performed[x]	M	x	x	x
Procedure Patient	The person, animal or group on which the procedure was performed.			US Core Procedure Profile	Procedure.subject	M			x
Medications, Immunizations, Allergies
Medication code	A code (or set of codes) that specify this medication, or a textual description if no code is available. Usage note: This could be a standard medication code such as a code from RxNorm, SNOMED CT, IDMP etc. It could also be a national or local formulary code, optionally with translations to other code systems.	Medications	Medications	US Core Medication Profile	Medication.code	M	x	x	x
Medication requested	Identifies the medication being requested. This is a link to a resource that represents the medication which may be the details of the medication or simply an attribute carrying a code that identifies the medication from a known list of medications.	Medications	Medications	US Core Medication Profile	MedicationRequest.medication[x]	M
Medication request status	A code specifying the current state of the order. Generally, this will be active or completed state.	Medications	Medications	US Core Medication Request Profile	MedicationRequest.status	M	x	x	x	http://hl7.org/fhir/ValueSet/medicationrequest-status
Medication request intent	Whether the request is a proposal, plan, or an original order.	Medications	Medications	US Core Medication Request Profile	MedicationRequest.intent	M	x	x	x	http://hl7.org/fhir/ValueSet/medicationrequest-intent
Medication Request Date/time Originally Written	The date (and perhaps time) when the prescription was initially written or authored on.	Medications	Medications	US Core Medication Request Profile	MedicationRequest.authoredOn	M	x	x	x
Medication Request Patient	A link to a resource representing the person or set of individuals to whom the medication will be given.			US Core Medication Request Profile	MedicationRequest.subject	M			x
Medication Requester	The individual, organization, or device that initiated the request and has responsibility for its activation.	Medications	Medications	US Core Medication Request Profile	MedicationRequest.requester	M	x	x	x
Medication Request Reported	Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record. It may also indicate the source of the report.	Medications	Medications	US Core Medication Request Profile	MedicationRequest.reported[x]	S	x	x	x
Medication Request Encounter	The Encounter during which this [x] was created or to which the creation of this record is tightly associated.	Medications	Medications	US Core Medication Request Profile	MedicationRequest.encounter	S	x	x	x
Medication dosage instructions	Indicates how the medication is to be used by the patient.	Medications	Medications	US Core Medication Request Profile	MedicationRequest.dosageInstruction.text	S	x	x	x
Immunization Status	Indicates the current status of the immunization event.	Immunizations	Immunizations	US Core Immunization Profile	Immunization.status	M	x	x	x
Vaccine Administered Code	Vaccine that was administered or was to be administered.	Immunizations	Immunizations	US Core Immunization Profile	Immunization.vaccineCode	M
Vaccine Administered Date/time	Date vaccine administered or was to be administered.	Immunizations	Immunizations	US Core Immunization Profile	Immunization.occurrence[x]	M	x	x	x
Reason immunization event not performed	Indicates the reason the immunization event was not performed.	Immunizations	Immunizations	US Core Immunization Profile	Immunization.statusReason	S
Immunization Primary Source	An indication that the content of the record is based on information from the person who administered the vaccine. This reflects the context under which the data was originally recorded.	Immunizations	Immunizations	US Core Immunization Profile	Immunization.primarySource	M
Immunization Patient	The patient who either received or did not receive the immunization.			US Core Immunization Profile	Immunization.patient	M			x
Medication administered	Identifies the medication that was administered. This is either a link to a resource representing the details of the medication or a simple attribute carrying a code that identifies the medication from a known list of medications.			MedicationAdministration	MedicationAdministration.medication[x]	M	x	x	x
Medication Patient	The person or animal or group receiving the medication.			MedicationAdministration	MedicationAdministration.subject	M			x
Medication administration 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.			MedicationAdministration	MedicationAdministration.status	M	x	x	x
Medication administration status reason	A code indicating why the administration was not performed.			MedicationAdministration	MedicationAdministration.statusReason	0	x	x	x
Medication administration context	The visit, admission, or other contact between patient and health care provider during which the medication administration was performed.			MedicationAdministration	MedicationAdministration.context	0	x	x	x
Date/time medication administered	A specific date/time or interval of time during which the administration took place (or did not take place, when the 'notGiven' attribute is true). For many administrations, such as swallowing a tablet the use of dateTime is more appropriate.			MedicationAdministration	MedicationAdministration.effective[x]	M	x	x	x
Medication administration performer	Indicates who or what performed the medication administration and how they were involved.			MedicationAdministration	MedicationAdministration.performer	0	x	x	x
Medication administration dosage	Describes the medication dosage information details e.g. dose, rate, site, route, etc.			MedicationAdministration	MedicationAdministration.dosage	0	x	x	x
Allergy clinical status	The clinical status of the allergy or intolerance.	Allergies and Intolerances	Reaction	US Core Allergies Profile	AllergyIntolerance.clinicalStatus	S	x	x	x	http://hl7.org/fhir/R4/valueset-allergyintolerance-clinical.html	Active
Allergy verification	Assertion about certainty associated with the propensity, or potential risk, of a reaction to the identified substance (including pharmaceutical product).	Allergies and Intolerances	Reaction	US Core Allergies Profile	AllergyIntolerance.verificationStatus	S	x	x	x
Allergy code	Code for an allergy or intolerance statement (either a positive or a negated/excluded statement). This may be a code for a substance or pharmaceutical product that is considered to be responsible for the adverse reaction risk (e.g., "Latex"), an allergy or intolerance condition (e.g., "Latex allergy"), or a negated/excluded code for a specific substance or class (e.g., "No latex allergy") or a general or categorical negated statement (e.g., "No known allergy", "No known drug allergies").	Allergies and Intolerances	Substance (Drug Class) Substance (Medication)	US Core Allergies Profile	AllergyIntolerance.code	M	x	x	x
Allergy Patient	Who the sensitivity is for			US Core Allergy Intolerance Profile	AllergyIntolerance.patient	M			x
Allergy Reaction	Details about each adverse reaction event linked to exposure to the identified substance.	Allergies and Intolerances	Reaction	US Core Allergies Profile	AllergyIntolerance.reaction	0	x	x	x
Allergy Reaction Manifestation	Clinical symptoms and/or signs that are observed or associated with the adverse reaction event.	Allergies and Intolerances	Reaction/ V1	US Core Allergy Intolerance Profile	AllergyIntolerance.reaction.manifestation	S	x	x	x
Vital Signs
Height LOINC code	Body height (LOINC code = 8302-2)	Vital Signs	Body height	Body height (FHIR Core Profile)	Observation.code.coding:BodyHeightCode.code	M	x	x	x	http://hl7.org/fhir/R4/valueset-observation-vitalsignresult.html	http://hl7.org/fhir/R4/observation-vitalsigns.html
Height value	The numeric value for the body height	Vital Signs	Body height	Body height (FHIR Core Profile)	Observation.valueQuantity.value	M	x	x	x		125
Height unit	The unit (string) for the body height value	Vital Signs	Body height	Body height (FHIR Core Profile)	Observation.valueQuantity.unit	M	x	x	x		cm
Height unit system	The system that defines the coded unit form for the body height value	Vital Signs	Body height	Body height (FHIR Core Profile)	Observation.valueQuantity.system	M	x	x	x	http://unitsofmeasure.org
Height unit code	The coded unit from the common UCUM units for the body height value	Vital Signs	Body height	Body height (FHIR Core Profile)	Observation.valueQuantity.code	M	x	x	x	http://hl7.org/fhir/R4/valueset-ucum-bodylength.html	cm
Height patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed.			Body height (FHIR Core Profile)	Observation.subject	M
Height date/time	Often just a dateTime for Vital Signs.			Body height (FHIR Core Profile)	Observation.effective[x]
Height data absent reason	Why the component result is missing			Body height (FHIR Core Profile)	Observation.component.dataAbsentReason
Height status	The status of the result value.			Body height (FHIR Core Profile)	Observation.status
Weight LOINC Code	Body weight (LOINC code = 29463-7)	Vital Signs	Body weight	Body weight (FHIR Core Profile)	Observation.code.coding:BodyWeightCode.code	M	x	x	x	http://loinc.org	29463-7
Weight value	The numeric value for the body weight	Vital Signs	Body weight	Body weight (FHIR Core Profile)	Observation.valueQuantity.value	M	x	x	x		70
Weight unit	The unit (string) for the body weight value	Vital Signs	Body weight	Body weight (FHIR Core Profile)	Observation.valueQuantity.unit	M	x	x	x		kg
Weight unit system	The system that defines the coded unit form for the body weight value	Vital Signs	Body weight	Body weight (FHIR Core Profile)	Observation.valueQuantity.system	M	x	x	x	http://unitsofmeasure.org
Weight unit code	The coded unit from the common UCUM units for the body weight value	Vital Signs	Body weight	Body weight (FHIR Core Profile)	Observation.valueQuantity.code	M	x	x	x	http://hl7.org/fhir/R4/valueset-ucum-bodyweight.html	kg
Weight patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed.			Body weight (FHIR Core Profile)	Observation.subject	M
Weight date/time	Often just a dateTime for Vital Signs.			Body weight (FHIR Core Profile)	Observation.effective[x]	M
Weight data absent reason	Why the component result is missing			Body weight (FHIR Core Profile)	Observation.component.dataAbsentReason	S
Weight status	The status of the result value.			Body weight (FHIR Core Profile)	Observation.status	M
Temperature LOINC Code	Body temperature (LOINC code = 8310-5)	Vital Signs	Body temperature	Body temperature (FHIR Core Profile)	Observation.code.coding:BodyTempCode.code	M	x	x	x	http://loinc.org	8310-5
Temperature value	The numeric value for the body temperature	Vital Signs	Body temperature	Body temperature (FHIR Core Profile)	Observation.valueQuantity.value	M	x	x	x		37
Temperature unit	The unit (string) for the body temperature value	Vital Signs	Body temperature	Body temperature (FHIR Core Profile)	Observation.valueQuantity.unit	M	x	x	x		C
Temperature unit system	The system that defines the coded unit form for the body temperature value	Vital Signs	Body temperature	Body temperature (FHIR Core Profile)	Observation.valueQuantity.system	M	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Temperature unit code	The coded unit from the common UCUM units for the body temperature value	Vital Signs	Body temperature	Body temperature (FHIR Core Profile)	Observation.valueQuantity.code	M	x	x	x	http://hl7.org/fhir/R4/valueset-ucum-bodytemp.html	Cel
Temperature patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed.			Body temperature (FHIR Core Profile)	Observation.subject	M
Temperature date/time	Often just a dateTime for Vital Signs.			Body temperature (FHIR Core Profile)	Observation.effective[x]	M
Temperature data absent reason	Why the component result is missing			Body temperature (FHIR Core Profile)	Observation.component.dataAbsentReason	S
Temperature status	The status of the result value.			Body temperature (FHIR Core Profile)	Observation.status	M
Blood pressure LOINC code	Blood pressure code (LOINC = 85354-9 )	Vital Signs	Blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.code.coding:BPCode.code	M	x	x	x	http://loinc.org	85354-9
Blood Pressure - Systolic LOINC Code	Systolic blood pressure(LOINC code = 8480-6)	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:systolicBP.code.coding:SBPCode.code	M	x	x	x	http://loinc.org	8480-6
Blood Pressure - Systolic value	The numeric value for the systolic blood pressure	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:systolicBP.valueQuantity.value	M	x	x	x		100
Blood Pressure - Systolic unit	The unit (string) for the systolic blood pressure value	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:systolicBP.valueQuantity.unit	M	x	x	x		mm/hg
Blood Pressure - Systolic unit system	The system that defines the coded unit form for the systolic blood pressure value	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:systolicBP.valueQuantity.system	M	x	x	x	http://unitsofmeasure.org
Blood Pressure patient	The coded unit from the common UCUM units for the systolic blood pressure value	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:systolicBP.valueQuantity.code	M	x	x	x	Fixed Value: mm[Hg]	mm[Hg]
Blood Pressure - Diastolic LOINC code	Diastolic blood pressure (LOINC code = 8462-4)	Vital Signs	Diastolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:systolicBP.code.coding:DBPCode.code	M	x	x	x	http://loinc.org	8462-4
Blood Pressure - Diastolic value	The numeric value for the diastolic blood pressure	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:diastolicBP.valueQuantity.value	M	x	x	x		60
Blood Pressure - Diastolic unit	The unit (string) for the diastolic blood pressure value	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:diastolicBP.valueQuantity.unit	M	x	x	x		mm/hg
Blood Pressure - Diastolic unit system	The system that defines the coded unit form for the diastolic blood pressure value	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:diastolicBP.valueQuantity.system	M	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Blood Pressure - Diastolic unit code	The coded unit from the common UCUM units for the diastolic blood pressure value	Vital Signs	Systolic blood pressure	Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component:diastolicBP.valueQuantity.code	M	x	x	x	Fixed Value: mm[Hg]	mm[Hg]
Blood Pressure patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed.			Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.subject	M
Blood Pressure date/time	Often just a dateTime for Vital Signs.			Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.effective[x]	M
Blood Pressure data absent reason	Why the component result is missing			Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.component.dataAbsentReason	S
Blood Pressure status	The status of the result value.			Blood pressure systolic and diastolic (FHIR Core Profile)	Observation.status	M
Respiratory rate per minute LOINC Code	Respiratory Rate (LOINC code = 9279-1)	Vital Signs	Respiratory rate	Respiratory rate (FHIR Core Profile)	Observation.code.coding:RespRateCode.code	M	x	x	x	http://loinc.org	9279-1
Respiratory rate per minute value	The numeric value for the respiratory rate	Vital Signs	Respiratory rate	Respiratory rate (FHIR Core Profile)	Observation.valueQuantity.value	M	x	x	x
Respiratory rate per minute unit	The unit (string) for the respiratory rate value	Vital Signs	Respiratory rate	Respiratory rate (FHIR Core Profile)	Observation.valueQuantity.unit	M	x	x	x
Respiratory rate per minute unit system	The system that defines the coded unit form for the respiratory rate value	Vital Signs	Respiratory rate	Respiratory rate (FHIR Core Profile)	Observation.valueQuantity.system	M	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Respiratory rate per minute unit code	The coded unit from the common UCUM units for the respiratory rate value	Vital Signs	Respiratory rate	Respiratory rate (FHIR Core Profile)	Observation.valueQuantity.code	M	x	x	x	Fixed Value: /min	/min
Respiratory Rate per Minute patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed.			Respiratory rate (FHIR Core Profile)	Observation.subject	M
Respiratory Rate per Minute date/time	Often just a dateTime for Vital Signs.			Respiratory rate (FHIR Core Profile)	Observation.effective[x]	M
Respiratory Rate per Minute data absent reason	Why the component result is missing			Respiratory rate (FHIR Core Profile)	Observation.component.dataAbsentReason	S
Respiratory Rate per Minute status	The status of the result value.			Respiratory rate (FHIR Core Profile)	Observation.status	M
Heart rate LOINC code	Heart Rate (LOINC code = 8867-4)	Vital Signs	Heart rate	Heart rate (FHIR Core Profile)	Observation.code.coding:HeartRateCode.code	M	x	x	x	http://loinc.org	8867-4
Heart rate value	The numeric value for the heart rate	Vital Signs	Heart rate	Heart rate (FHIR Core Profile)	Observation.valueQuantity.value	M	x	x	x		60
Heart rate unit	The unit (string) for the heart rate value	Vital Signs	Heart rate	Heart rate (FHIR Core Profile)	Observation.valueQuantity.unit	M	x	x	x		60/min
Heart rate unit system	The system that defines the coded unit form for the heart rate value	Vital Signs	Heart rate	Heart rate (FHIR Core Profile)	Observation.valueQuantity.system	M	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Heart rate unit code	The coded unit from the common UCUM units for the heart rate value	Vital Signs	Heart rate	Heart rate (FHIR Core Profile)	Observation.valueQuantity.code	M	x	x	x	Fixed Value: /min	/min
Heart Rate patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed.			Heart rate (FHIR Core Profile)	Observation.subject	M
Heart Rate date/time	Often just a dateTime for Vital Signs.			Heart rate (FHIR Core Profile)	Observation.effective[x]	M
Heart Rate data absent reason	Why the component result is missing			Heart rate (FHIR Core Profile)	Observation.component.dataAbsentReason	S
Heart Rate status	The status of the result value.			Heart rate (FHIR Core Profile)	Observation.status	M
pulse oximetry LOINC code	Oxygen saturation in Arterial blood by Pulse oximetry (LOINC code 59408-5)	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.code.coding:PulseOx.code	M	x	x	x	http://loinc.org	59408-5
Inhaled oxygen flow rate LOINC code	Inhaled oxygen flow rate (LOINC code = 3151-8)	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:FlowRate.code.coding.code	S	x	x	x	http://loinc.org	3151-8
Inhaled oxygen flow rate value	The numeric value for the Inhaled oxygen flow rate	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:FlowRate.valueQuantity.value	S	x	x	x		6
Inhaled oxygen flow rate unit	The unit (string) for the Inhaled oxygen flow rate value	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:FlowRate.valueQuantity.unit	S	x	x	x		L/min
Inhaled oxygen flow rate unit system	The system that defines the coded unit form for the Inhaled oxygen flow rate value	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:FlowRate.valueQuantity.system	S	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Inhaled oxygen flow rate unit code	The coded unit from the common UCUM units for the Inhaled oxygen flow rate value	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:FlowRate.valueQuantity.code	S	x	x	x	Fixed Value: L/min	L/min
Inhaled oxygen concentration LOINC code	Inhaled oxygen concentration (LOINC code = 3150-0)	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:Concentration.code.coding.code	S	x	x	x	http://loinc.org	3150-0
Inhaled oxygen concentration value	The numeric value for the Inhaled oxygen concentration	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:Concentration.valueQuantity.value	S	x	x	x		95
Inhaled oxygen concentration unit	The unit (string) for the Inhaled oxygen concentration value	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:Concentration.valueQuantity.unit	S	x	x	x		%
Inhaled oxygen concentration unit system	The system that defines the coded unit form for the Inhaled oxygen concentration value	Vital Signs	Pulse oximetry	US Core Pulse Oximetry Profile	Observation.component:Concentration.valueQuantity.system	S	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Inhaled oxygen concentration unit code	The coded unit from the common UCUM units for the Inhaled oxygen concentration value	Vital Signs	Inhaled oxygen concentration	US Core Pulse Oximetry Profile	Observation.component:Concentration.valueQuantity.code	S	x	x	x	Fixed Value: %	%
Pulse Oximetry patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed.			Heart rate (FHIR Core Profile)	Observation.subject	M
Pulse Oximetry date/time	Often just a dateTime for Vital Signs.			Heart rate (FHIR Core Profile)	Observation.effective[x]	M
Pulse Oximetry data absent reason	Why the component result is missing			Heart rate (FHIR Core Profile)	Observation.component.dataAbsentReason	S
Pulse Oximetry status	The status of the result value.			Heart rate (FHIR Core Profile)	Observation.status	M
Pediatric body mass index (BMI) per age and gender LOINC Code	pediatric body mass index (BMI) per age and gender observations associated with a patient. (LOINC code = 59576-9)	Vital Signs	BMI percentile per age and sex for youth 2-20	US Core Pediatric BMI for Age Observation Profile	Observation.code.coding.code	M	x	x	x	http://loinc.org	59576-9
Pediatric body mass index (BMI) per age and gender value	The numeric value for the pediatric body mass index (BMI) per age and gender	Vital Signs	BMI percentile per age and sex for youth 2-20	US Core Pediatric BMI for Age Observation Profile	Observation.valueQuantity.value	S	x	x	x		65
Pediatric body mass index (BMI) per age and gender unit	The unit (string) for the pediatric body mass index (BMI) per age and gender value	Vital Signs	BMI percentile per age and sex for youth 2-20	US Core Pediatric BMI for Age Observation Profile	Observation.valueQuantity.unit	S	x	x	x		%
Pediatric body mass index (BMI) per age and gender unit system	The system that defines the coded unit form for the pediatric body mass index (BMI) per age and gender value	Vital Signs	BMI percentile per age and sex for youth 2-20	US Core Pediatric BMI for Age Observation Profile	Observation.valueQuantity.system	S	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Pediatric body mass index (BMI) per age and gender unit code	The coded unit from the common UCUM units for the pediatric body mass index (BMI) per age and gender value	Vital Signs	BMI percentile per age and sex for youth 2-20	US Core Pediatric BMI for Age Observation Profile	Observation.valueQuantity.code	S	x	x	x	Fixed Value: %	%
Pediatric Body Mass Index (BMI) per Age and Gender patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.			US Core Pediatric BMI for Age Observation Profile	Observation.subject	M
Pediatric Body Mass Index (BMI) per Age and Gender effective[x]	Often just a dateTime for Vital Signs	Vital Signs	Vital sign results: date and timestamps	US Core Pediatric BMI for Age Observation Profile	Observation.effective[x]	M
Pediatric Body Mass Index (BMI) per Age and Gender data absent reason	Why the result is missing			US Core Pediatric BMI for Age Observation Profile	Observation.dataAbsentReason	S
Pediatric Body Mass Index (BMI) per Age and Gender status	The status of the result value.			US Core Pediatric BMI for Age Observation Profile	Observation.status	M
Pediatric weight for height and age LOINC code	The pediatric weight for height and age observations associated with a patient. (LOINC code = 77606-2)	Vital Signs	Weights for age per length and sex	US Core Pediatric Weight for Height Observation Profile	Observation.code.coding.code	M	x	x	x	http://loinc.org	77606-2
Pediatric weight for height and age value	The numeric value for the pediatric weight for height and age	Vital Signs	Weights for age per length and sex	US Core Pediatric Weight for Height Observation Profile	Observation.valueQuantity.value	S	x	x	x		65
Pediatric weight for height and age unit	The unit (string) for the pediatric weight for height and age value	Vital Signs	Weights for age per length and sex	US Core Pediatric Weight for Height Observation Profile	Observation.valueQuantity.unit	S	x	x	x		%
Pediatric weight for height and age unit system	The system that defines the coded unit form for the pediatric weight for height and age value	Vital Signs	Weights for age per length and sex	US Core Pediatric Weight for Height Observation Profile	Observation.valueQuantity.system	S	x	x	x	Fixed Value: http://unitsofmeasure.org	http://unitsofmeasure.org
Pediatric weight for height and age unit code	The coded unit from the common UCUM units for the pediatric weight for height and age value	Vital Signs	Weights for age per length and sex	US Core Pediatric Weight for Height Observation Profile	Observation.valueQuantity.code	S	x	x	x	Fixed Value: %	%
Pediatric Weight for Height and Age patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.			US Core Pediatric Weight for Height Observation Profile	Observation.subject	M
Pediatric Weight for Height and Age effective[x]	Often just a dateTime for Vital Signs	Vital Signs	Vital sign results: date and timestamps	US Core Pediatric Weight for Height Observation Profile	Observation.effective[x]	M
Pediatric Weight for Height and Age data absent reason	Why the result is missing			US Core Pediatric Weight for Height Observation Profile	Observation.dataAbsentReason	S
Pediatric Weight for Height and Age status	The status of the result value.			US Core Pediatric Weight for Height Observation Profile	Observation.status	M
Occipital-frontal circumference for children < 3 years old LOINC code	Occipital-frontal circumference for children < 3 years old. (LOINC code = 8289-1)	Vital Signs	Occipital-frontal circumference for children < 3 years old	Head circumference (FHIR Core Profile)	Observation.code.coding.code	M	x	x	x	http://loinc.org	8289-1
Occipital-frontal circumference for children < 3 years old value	The numeric value for the occipital-frontal circumference	Vital Signs	Occipital-frontal circumference for children < 3 years old	Head circumference (FHIR Core Profile)	Observation.valueQuantity.value	S	x	x	x		82
Occipital-frontal circumference for children < 3 years old unit	The unit (string) for the occipital-frontal circumference value	Vital Signs	Occipital-frontal circumference for children < 3 years old	Head circumference (FHIR Core Profile)	Observation.valueQuantity.unit	S	x	x	x		%
Occipital-frontal circumference for children < 3 years old unit system	The system that defines the coded unit form for the occipital-frontal circumference value	Vital Signs	Occipital-frontal circumference for children < 3 years old	Head circumference (FHIR Core Profile)	Observation.valueQuantity.system	S	x	x	x		Fixed Value: http://unitsofmeasure.org
Occipital-frontal circumference for children < 3 years old unit code	The coded unit from the common UCUM units for the occipital-frontal circumference value	Vital Signs	Occipital-frontal circumference for children < 3 years old	Head circumference (FHIR Core Profile)	Observation.valueQuantity.code	S	x	x	x		Fixed Value: %
Occipital-Frontal Circumference for Children < 3 Years Old patient	The patient, or group of patients, location, or device this observation is about and into whose record the observation is placed. If the actual focus of the observation is different from the subject (or a sample of, part, or region of the subject), the focus element or the code itself specifies the actual focus of the observation.			Head circumference (FHIR Core Profile)	Observation.subject	M			x
Occipital-Frontal Circumference for Children < 3 Years Old effective[x]	Often just a dateTime for Vital Signs	Vital Signs	Vital sign results: date and timestamps	Head circumference (FHIR Core Profile)	Observation.effective[x]	M			x
Occipital-Frontal Circumference for Children < 3 Years Old data absent reason	Why the result is missing			Head circumference (FHIR Core Profile)	Observation.dataAbsentReason	S			x
Occipital-Frontal Circumference for Children < 3 Years Old status	The status of the result value.			Head circumference (FHIR Core Profile)	Observation.status	M			x
Unique Device Identifier(s) for a patient’s implantable device(s)
Unique device identifier	Unique device identifier (UDI) assigned to device label or package. Note that the Device may include multiple udiCarriers as it either may include just the udiCarrier for the jurisdiction it is sold, or for multiple jurisdictions it could have been sold.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.udiCarrier	S	x	x	x
Device identifier	The device identifier (DI) is a mandatory, fixed portion of a UDI that identifies the labeler and the specific version or model of a device.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.udiCarrier.deviceIdentifier	S	x	x	x
Device AIDC	The full UDI carrier of the Automatic Identification and Data Capture (AIDC) technology representation of the barcode string as printed on the packaging of the device - e.g., a barcode or RFID. Because of limitations on character sets in XML and the need to round-trip JSON data through XML, AIDC Formats SHALL be base64 encoded.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.udiCarrier.carrierAIDC	S	x	x	x
Device HRF barcode	The full UDI carrier as the human readable form (HRF) representation of the barcode string as printed on the packaging of the device.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.udiCarrier.carrierHRF	S	x	x	x
Device distinct identifier	The distinct identification string as required by regulation for a human cell, tissue, or cellular and tissue-based product.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.distinctIdentifier	S	x	x	x
Device manufactured date/time	The date and time when the device was manufactured.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.manufactureDate	S	x	x	x
Device expiration date	The date and time beyond which this device is no longer valid or should not be used (if applicable).	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.expirationDate	S	x	x	x
Device lot number	Lot number assigned by the manufacturer.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.lotNumber	S	x	x	x
Device serial number	The serial number assigned by the organization when the device was manufactured.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device.serialNumber	S	x	x	x
Device type	The kind or type of device.	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	Unique Device Identifier(s) for a Patient’s Implantable Device(s)	US Core Implantable Device Profile	Device type	M	x	x	x	http://hl7.org/fhir/ValueSet/device-kind	Prosthetic mitral valve
Device Patient	Patient information, If the device is affixed to a person.			US Core Implantable Device Profile	Device.patient	M
Assessment and Plan of Treatment
Care plan summary	A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.	Assessment and Plan of Treatment	Assessment and Plan of Treatment	US Core CarePlan Profile	CarePlan.text	M	x	x	x
Care plan summary status	generated \| additional.	Assessment and Plan of Treatment	Assessment and Plan of Treatment	US Core CarePlan Profile	CarePlan.text.status	M	x	x	x	http://hl7.org/fhir/us/core/ValueSet/us-core-narrative-status	Additional
Care plan status	Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.	Assessment and Plan of Treatment	Assessment and Plan of Treatment	US Core CarePlan Profile	CarePlan.status	M	x	x	x	http://hl7.org/fhir/ValueSet/request-status	Draft
Care plan intent	Indicates the level of authority/intentionality associated with the care plan and where the care plan fits into the workflow chain.	Assessment and Plan of Treatment	Assessment and Plan of Treatment	US Core CarePlan Profile	CarePlan.intent	M	x	x	x	http://hl7.org/fhir/ValueSet/care-plan-intent	Proposal
Care plan type	Type of plan.	Assessment and Plan of Treatment	Assessment and Plan of Treatment	US Core CarePlan Profile	CarePlan.category:AssessPlan	M	x	x	x	http://hl7.org/fhir/ValueSet/care-plan-category	Fixed Value: Assess Plan
Care Plan Patient	Who care plan is for.			US Core CarePlan Profile	CarePlan.subject	M
Care Plan Ordered service				US Core CarePlan Profile	CarePlan.activity.reference.ServiceRequest.code	O
Provenance
Provenance resource	The Reference(s) that were generated or updated by the activity described in this resource. A provenance can point to more than one target if multiple resources were created/updated by the same activity. The Resource this Provenance record supports	Provenance		US Core Provenance Profile	Provenance.target	M	x	x	x
Provenance timestamp	The instant of time at which the activity was recorded.	Provenance	Author Time Stamp	US Core Provenance Profile	Provenance.recorded	M	x	x	x
Provenance agent type	The participation the agent had with respect to the activity.	Provenance		US Core Provenance Profile	Provenance.agent.type	S	x	x	x	http://hl7.org/fhir/us/core/ValueSet/us-core-provenance-participant-type	Author (A party that originates the resource and therefore has responsibility for the information given in the resource and ownership of this resource)
Provenance agent	The identity of the person or entity who is the agent.	Provenance	Author Organization	US Core Provenance Profile	Provenance.agent.who	M	x	x	x		Reference(USCorePractitionerProfile \| USCorePatientProfile \| USCoreOrganizationProfile)
Provenance on behalf of	The individual, device, or organization for whom the change was made.	Provenance		US Core Provenance Profile	Provenance.agent.onBehalfOf	S	x	x	x
Provenance author	An actor taking a role in an activity for which it can be assigned some degree of responsibility for the activity taking place.	Provenance		US Core Provenance Profile	Provenance.agent:ProvenanceAuthor.type.code	S	x	x	x	Fixed Value: http://terminology.hl7.org/CodeSystem/provenance-participant-type	Fixed Value: author
Provenance transmitter	The entity that provided the copy to your system.	Provenance		US Core Provenance Profile	Provenance.agent:ProvenanceTransmitter.type.code	S	x	x	x	Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-provenance-participant-type	Fixed Value: transmitter
Patient Goals
Patient's goal status	The state of the goal throughout its lifecycle.	Goals	Patient's goals	US Core Goal Profile	Goal.lifecycleStatus	M	x	x	x	http://hl7.org/fhir/ValueSet/goal-status	Proposed
Patient's goal description	Human-readable and/or coded description of a specific desired objective of care, such as "control blood pressure" or "negotiate an obstacle course" or "dance with child at wedding".	Goals	Patient's goals	US Core Goal Profile	Goal.description	M	x	x	x
Patient's goal target date	Indicates either the date or the duration after start by which the goal should be met.	Goals	Patient's goals	US Core Goal Profile	Goal.target.due[x]	S	x	x	x
Goal Patient	Identifies the patient, group or organization for whom the goal is being established.			US Core Goal Profile	Goal.subject	M

** M = Mandatory; S = Must Support; 0 = not M or S

*** Included examples should be treated as a reference for the convenience of the reader.

Policy Considerations

The policy considerations for the use case to be implemented in the real-world include:

MedMorph will use existing frameworks (e.g., FHIR APIs) for the exchange of data.
When there is a third party, a data use or business use/associate agreement may be needed (e.g., Association of Public Health Laboratories (APHL)).
Public Health Authorities (PHAs) may have state-specific restrictions on collecting protected classes of data (e.g., AIDS status, mental health status, Substance Use Disorder/Opioid Use Disorder (SUD/OUD)).
- If the patient gives consent for sharing of AIDs, mental health, etc. data the burden would be on the sending system.
- For research use cases, there must be consent before the data is sent.
For jurisdictional restrictions on data that can not be collected, the MedMorph Reference Architecture will make provisions for defining actions (e.g., redaction, filtering, removal, validation) before submission. The actions could be triggered based on the content of specific data elements.
- The MedMorph Reference Architecture will do an additional validation check on the data before the data leaves the healthcare organization. This is important in cases of a healthcare organization reporting to multiple jurisdictions.

Non-Technical Considerations

The policy considerations for the use case to be implemented in the real-world include:

Onboarding of EHRs and or tracking systems
The use, IT/data governance, and or versioning of FHIR between trading entities
Consent models for data exchange:
- For public health purposes, existing authorities are sufficient and no consent is required.
- For research use cases:
  - Institutional Review Boards (IRB) approvals, intended purpose, and consent for the intended purpose is included
  - Other areas to investigate:
    - https://www.hl7.org/fhir/consent.html (Look at ResearchSubject and ResearchStudy resources in FHIR and their relationship to Consent Resource)
    - Patient-Level data, Limited Data Set (LDS), Deidentified data sets, and relationships to consent
    - Leading Edge Acceleration Projects (LEAP) in Health Information Technology (Health IT) | HealthIT.gov
Data that is stored outside the EHR (e.g., Prescription Drug Monitoring Progam (PDMP) data, Hepatitis C wants drug use data) may not be available
Any activities that are not associated with a clinical order or clinical visit (e.g., drive-up COVID test, Sexually Transmitted Disease (STD) test, adult immunization at the pharmacy)
Data lag vs. real-time (especially for research use cases) - the difference in time for use cases.
- The Reference Architecture defines trigger events and timing offsets in relationship to trigger events, and actions to be performed based on trigger events.
Data provenance (recognized authority - but how much do we trust the data from those systems outside of the EHR and the EHR ingests the data - and the detail of information and method of transmission (e.g., orally reported, substantiated with material or electronic)
- The MedMorph Reference Architecture IG would recommend (or require in available) support for Provenance as defined by USCDI and apply to all data classes being reported.
Registries will capture what they are required to capture by state laws and standards setters, but research use cases might want to capture complications, etc. related to cancer.
- Acknowledgment that state laws and standards can preempt/modify/exclude data that could occur in a content (use case) specific IG.

Appendices

References to Appropriate Documentation

National Center for Health Statistics (NCHS): https://www.cdc.gov/nchs/index.htm
National Health Care Surveys (NHCS): https://www.cdc.gov/nchs/dhcs/index.htm
National Health Care Surveys Registry: https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm
HL7 CDA® R2 Implementation Guide: National Health Care Surveys: https://www.hl7.org/implement/standards/product_brief.cfm?product_id=385
USCDI: https://www.healthit.gov/isa/us-core-data-interoperability-uscdi

Terms and Definitions

Ambulatory Setting: Medical services performed on an outpatient basis, without admission to a hospital or other facility. It is provided in settings such as physician offices, hospital outpatient departments, ambulatory surgical centers, and clinics (including Community Health Centers). (adapted from https://www.ipfcc.org/)

Application Programming Interface (API): A computing interface which defines interactions between multiple software intermediaries.

Clinical Encounter: Any physical or virtual contact between a patient (or trial subject) and healthcare provider at which an assessment or activity takes place. (from https://ncit.nci.nih.gov/)

Electronic Health Record (EHR): A system used in care delivery for patients and captures and stores data about patients and makes the information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s provision of care location and can be inclusive of a broader view of a patient’s care. EHRs are a vital part of health IT and can:

Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results
Allow access to evidence-based tools that providers can use to make decisions about a patient’s care
Automate and streamline provider workflow

A FHIR Enabled EHR exposes FHIR APIs for other systems to interact with the EHR and exchange data. FHIR APIs provide well defined mechanisms to read and write data. The FHIR APIs are protected by an Authorization Server which authenticates and authorizes users or systems prior to accessing the data.

Fast Healthcare Interoperability Resource (FHIR) Specification: A standard for exchanging healthcare information electronically developed by Health Level Seven International (HL7).

Health Care Survey: Designed to answer key questions of interest to health care policy makers, public health professionals, and researchers. These can include the factors that influence the use of health care resources, the quality of health care, including safety, and disparities in health care services provided to population subgroups in the United States. (from https://www.cdc.gov/nchs/dhcs/index.htm )

HL7 FHIR Encounter Resource: An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient. (from http://hl7.org/fhir/R4/encounter.html)

Inpatient Setting: Medical services involving a patient treated for a brief but severe episode of illness, for conditions that are the result of disease or trauma, and during recovery from surgery.

Public Health Authority (PHA): A government or a government designated organization that may receive the data from Trusted Third Parties or provider organizations using appropriate authorities and policies. PHA may also analyze the data and initiate responses back to clinical care. For more detailed information on PHA please refer to Public Health .

SMART on FHIR: Substitutable Medical Applications, Reusable Technologies on Fast Healthcare Interoperability Resource.

Use Case: Document used to capture user (actor) point of view while describing functional requirements of the system. They describe the step by step process a user goes through to complete that goal using a software system. A Use Case is a description of the ways an end-user wants to "use" a system. Use Cases capture ways the user and system can interact that result in the user achieving the goal. (adapted from https://www.visual-paradigm.com/)

User Story: A User Story is a note that captures what a user does or needs to do as part of his/her work. Each User Story consists of a short description written from user's point of view, with natural language. (adapted from https://www.visual-paradigm.com/)

[1] https://www.cdc.gov/nchs/ahcd/namcs_participant.htm

[2] https://www.cdc.gov/nchs/nhcs/about_nhcs.htm

[3] Adapted from https://www.healthit.gov/faq/what-electronic-health-record-ehr

MedMorph

Health Care Survey Reporting Use Case

Table of Contents