PATIENT ADMINISTRTAION (PA) Workgroup Development Draft

4.0 Clinical Resources


General
Resources that provide core clinical record keeping - focused on the content of the provider/patient encounter
NameAliasesDescription
AllergyIntoleranceAllergy, IntoleranceRisk of harmful or undesirable, physiological response which is unique to an individual and associated with exposure to a substance.
ClinicalImpressionA record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.
ConditionUse to record detailed information about conditions, problems or diagnoses recognized by a clinician. There are many uses including: recording a Diagnosis during an Encounter; populating a problem List or a Summary Statement, such as a Discharge Summary.
ReferralRequestReferralRequest TransferOfCare RequestUsed to record and send details about a request for referral service or transfer of a patient to the care of another provider or provider organisation.
ProcedureAn action that is or was performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counseling or hypnotherapy.
ContraindicationDDI, drug-drug interaction, DetectedIssueIndicates an actual or potential clinical issue with or between one or more active or proposed clinical actions for a patient. E.g. Drug-drug interaction, Ineffective treatment frequency, Procedure-condition conflict, etc.
RiskAssessmentPrognosisAn assessment of the likely outcome(s) for a patient or other subject as well as the likelihood of each outcome.

Data Collection/Care Plan
Support the collecting data, and managing the care process
NameAliasesDescription
QuestionnaireForm, CRFA structured set of questions intended to guide the collection of answers. The questions are ordered and grouped into coherent subsets, corresponding to the structure of the grouping of the underlying questions.
QuestionnaireAnswersFormA structured set of questions and their answers. The questions are ordered and grouped into coherent subsets, corresponding to the structure of the grouping of the underlying questions.
FamilyMemberHistorySignificant health events and conditions for a person related to the patient relevant in the context of care for the patient.
CarePlanCare TeamDescribes the intention of how one or more practitioners intend to deliver care for a particular patient for a period of time, possibly limited to care for a specific condition or set of conditions.
GoalDescribes the intended objective(s) of patient care, for example, weight loss, restoring an activity of daily living, etc.

Medication, Immunization & Nutrition
Support the medication, immunization & nutrition processes
NameAliasesDescription
MedicationPrimarily used for identification and definition of Medication, but also covers ingredients and packaging.
MedicationPrescriptionAn order for both supply of the medication and the instructions for administration of the medicine to a patient.
MedicationAdministrationDescribes the event of a patient consuming or otherwise being administered a medication. This may be as simple as swallowing a tablet or it may be a long running infusion. Related resources tie this event to the authorizing prescription, and the specific encounter between patient and health care practitioner.
MedicationDispenseDispensing a medication to a named patient. This includes a description of the supply provided and the instructions for administering the medication.
MedicationStatementA record of medication being taken by a patient, or that the medication has been given to a patient where the record is the result of a report from the patient or another clinician.
NutritionOrderDiet Order, Diet, Nutritional SupplementA request to supply a diet, formula feeding (enteral) or oral nutritional supplement to a patient/resident.
ImmunizationImmunization event information.
ImmunizationRecommendationA patient's point-of-time immunization status and recommendation with optional supporting justification.

Diagnostics
Provider support for diagnostic services - lab, pathology, imaging, etc
NameAliasesDescription
ObservationVital Signs, Measurement, ResultsMeasurements and simple assertions made about a patient, device or other subject.
DiagnosticReportReport, Test, Result, Results, LabsThe findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretation, and formatted representation of diagnostic reports.
DiagnosticOrderA record of a request for a diagnostic investigation service to be performed.
ImagingStudyManifest, XDS-I summaryRepresentation of the content produced in a DICOM imaging study. A study comprises a set of Series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A Series is of only one modality (e.g., X-ray, CT, MR, ultrasound), but a Study may have multiple Series of different modalities.
ImagingObjectSelectionImageManifest KeyImageNoteA set of DICOM SOP Instances of a patient, selected for some application purpose, e.g., quality assurance, teaching, conference, consulting, etc. Objects selected can be from different studies, but must be of the same patient.
SpecimenSample for analysis.

Additional Resources will be added in the future. A list of hypothesized resources can be found on the HL7 wiki. Feel free to add any you think are missing or engage with one of the HL7 Work Groups to submit a proposal to define a resource of particular interest.