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RCMR_HD000030UV01 Medical Records HMD | This RMIM is used to derive Medical Records speciications. (Link to Excel View) Derived from RMIM: RCMR_RM000030
ClinicalDocument |
classCode [1..1] (M) Act (CS) {CNE:DOCCLIN, default= "DOCCLIN"} |
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} |
id [1..1] Act (II) |
code [1..1] Act (CE) {CWE:DocumentType} |
text [0..1] Act (ED) |
statusCode [1..1] Act (CS) {CNE:ActStatus} |
effectiveTime [1..1] Act (TS) |
availabilityTime [0..1] Act (TS) |
confidentialityCode [0..1] Act (CE) {CWE:x_BasicConfidentialityKind, default= "N"} |
reasonCode [0..1] Act (CE) {CWE:ActReason} |
languageCode [0..1] Act (CS) {CNE:HumanLanguage} |
setId [0..1] ContextStructure (II) |
versionNumber [0..1] ContextStructure (INT) |
completionCode [0..1] Document (CE) {CWE:DocumentCompletion} |
storageCode [0..1] Document (CE) {CWE:DocumentStorage} |
copyTime [0..1] Document (TS) |
subject [0..*] (Subject) |
recordTarget [1..*] (RecordTarget) |
responsibleParty [0..1] (ResponsibleParty) |
author [1..*] (Author1) |
dataEnterer [0..1] (DataEnterer) |
custodian [1..1] (Custodian) |
informationRecipient [0..*] (InformationRecipient) |
legalAuthenticator [0..1] (LegalAuthenticator) |
authenticator [0..*] (Authenticator) |
participant [0..*] (Participant) |
inFulfillmentOf [0..*] (InFulfillmentOf) |
documentationOf [0..*] (DocumentationOf) |
relatedDocument [0..*] (RelatedDocument2) |
componentOf [0..1] (Component1) |
Subject |
typeCode [1..1] (M) Participation (CS) {CNE:SBJ, default= "SBJ"} |
subjectRole [1..1] (SubjectRole) |
SubjectRole |
classCode [1..1] (M) Role (CS) {CNE:x_DocumentSubject} |
code [0..1] Role (CE) {CWE:RoleCode} |
addr [0..*] Role (BAG<AD>) |
telecom [0..*] Role (BAG<TEL>) |
subject [0..1] (SubjectPerson) |
SubjectPerson |
classCode [1..1] (M) Entity (CS) {CNE:PSN, fixed value= "PSN"} |
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} |
name [0..*] Entity (BAG<PN>) |
administrativeGenderCode [0..1] LivingSubject (CE) {CWE:AdministrativeGender} |
birthTime [0..1] LivingSubject (TS) |
RecordTarget |
typeCode [1..1] (M) Participation (CS) {CNE:RCT, fixed value= "RCT"} |
patient [1..1] (R_PatientUniversal) |
ResponsibleParty |
typeCode [1..1] (M) Participation (CS) {CNE:RESP, fixed value= "RESP"} |
assignedPerson [1..1] (R_AssignedPersonUniversal) |
Author1 |
typeCode [1..1] (M) Participation (CS) {CNE:AUT, fixed value= "AUT"} |
functionCode [0..1] Participation (CE) {CWE:ParticipationFunction} |
time [1..1] Participation (TS) |
assignedAuthor [1..1] (AssignedAuthor) |
AssignedAuthor |
classCode [1..1] (M) Role (CS) {CNE:ASSIGNED, default= "ASSIGNED"} |
id [1..1] Role (II) |
code [0..1] Role (CE) {CWE:RoleCode} |
addr [0..*] Role (BAG<AD>) |
telecom [0..*] Role (BAG<TEL>) |
assignedAuthorChoice [0..1] (AuthorChoice) |
representedOrganization [0..1] (E_OrganizationUniversal) |
AuthorChoice |
choice of Person |
or AuthoringDevice |
Person |
classCode [1..1] (M) Entity (CS) {CNE:PSN, fixed value= "PSN"} |
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} |
name [0..*] Entity (BAG<PN>) |
AuthoringDevice |
classCode [1..1] (M) Entity (CS) {CNE:DEV, default= "DEV"} |
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} |
code [0..1] Entity (CE) {CWE:EntityCode} |
softwareName [0..1] Device (SC) |
DataEnterer |
typeCode [1..1] (M) Participation (CS) {CNE:ENT, fixed value= "ENT"} | Transcriptionist
time [0..1] Participation (TS) |
assignedPerson [1..1] (R_AssignedPersonUniversal) |
Custodian |
typeCode [1..1] (M) Participation (CS) {CNE:CST, fixed value= "CST"} |
assignedCustodian [1..1] (AssignedCustodian) |
AssignedCustodian |
classCode [1..1] (M) Role (CS) {CNE:ASSIGNED, default= "ASSIGNED"} |
representedOrganization [1..1] (E_OrganizationUniversal) |
InformationRecipient |
typeCode [1..1] (M) Participation (CS) {CNE:x_InformationRecipient} |
intendedRecipient [1..1] (IntendedRecipient) |
IntendedRecipient |
classCode [1..1] (M) Role (CS) {CNE:x_InformationRecipientRole} |
id [1..1] Role (II) |
addr [0..1] Role (AD) |
telecom [0..1] Role (TEL) |
informationRecipient [0..1] (Person) |
receivedOrganization [0..1] (E_OrganizationUniversal) |
LegalAuthenticator |
typeCode [1..1] (M) Participation (CS) {CNE:LA, fixed value= "LA"} |
time [0..1] Participation (TS) |
signatureCode [0..1] Participation (CE) {CNE:ParticipationSignature, default= "S"} |
assignedPerson [1..1] (R_AssignedPersonUniversal) |
Authenticator |
typeCode [1..1] (M) Participation (CS) {CNE:AUTHEN, fixed value= "AUTHEN"} |
time [0..1] Participation (TS) |
signatureCode [0..1] Participation (CE) {CNE:ParticipationSignature, default= "S"} |
assignedPerson [1..1] (R_AssignedPersonUniversal) |
Participant |
typeCode [1..1] (M) Participation (CS) {CNE:ParticipationType} |
functionCode [0..1] Participation (CE) {CWE:ParticipationFunction} |
time [0..1] Participation (IVL<TS>) |
signatureCode [0..1] Participation (CE) {CNE:ParticipationSignature} |
participatingEntity [1..1] (ParticipatingEntity) |
ParticipatingEntity |
classCode [1..1] (M) Role (CS) {CNE:RoleClassAssociative} |
id [0..1] Role (II) |
code [0..1] Role (CE) {CWE:RoleCode} |
addr [0..1] Role (AD) |
telecom [0..1] Role (TEL) |
associatedPerson [0..1] (Person) |
scopingOrganization [0..1] (E_OrganizationUniversal) |
InFulfillmentOf |
typeCode [1..1] (M) ActRelationship (CS) {CNE:FLFS, default= "FLFS"} |
order [1..1] (Order) |
Order |
classCode [1..1] (M) Act (CS) {CNE:ACT, default= "ACT"} |
moodCode [1..1] (M) Act (CS) {CNE:RQO, fixed value= "RQO"} |
id [1..1] Act (II) |
code [0..1] Act (CE) {CWE:ActCode} |
DocumentationOf |
typeCode [1..1] (M) ActRelationship (CS) {CNE:DOC, fixed value= "DOC"} |
event [1..1] (Event) |
Event |
classCode [1..1] (M) Act (CS) {CNE:ACT, default= "ACT"} |
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} |
id [1..*] Act (SET<II>) |
code [0..1] Act (CE) {CWE:ActCode} |
RelatedDocument2 |
typeCode [1..1] (M) ActRelationship (CS) {CNE:x_ActRelationshipDocument} |
parentDocument [1..1] (ParentDocument) |
ParentDocument |
classCode [1..1] (M) Act (CS) {CNE:DOCCLIN, default= "DOCCLIN"} |
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} |
id [1..1] Act (II) |
statusCode [0..1] Act (CS) {CNE:ActStatus} |
setId [0..1] ContextStructure (II) |
versionNumber [0..1] ContextStructure (INT) |
Component1 |
typeCode [1..1] (M) ActRelationship (CS) {CNE:COMP, default= "COMP"} |
encounterEvent [1..1] (EncounterEvent) |
EncounterEvent |
classCode [1..1] (M) Act (CS) {CNE:ENC, fixed value= "ENC"} |
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} |
id [0..1] Act (II) |
effectiveTime [1..1] Act (IVL<TS>) |
encounterPerformer [0..*] (EncounterPerformer) |
location [0..1] (Location) |
EncounterPerformer |
typeCode [1..1] (M) Participation (CS) {CNE:x_EncounterPerformerParticipation} |
functionCode [0..1] Participation (CE) {CWE:ParticipationFunction} |
time [0..1] Participation (IVL<TS>) |
assignedPerson [1..1] (R_AssignedPersonUniversal) |
Location |
typeCode [1..1] (M) Participation (CS) {CNE:LOC, default= "LOC"} |
healthCareFacility [1..1] (HealthCareFacility) |
HealthCareFacility |
classCode [1..1] (M) Role (CS) {CNE:SDLOC, default= "SDLOC"} |
id [0..1] Role (II) |
code [0..1] Role (CE) {CWE:ServiceDeliveryLocationRoleType} |
location [0..1] (Place) |
serviceProviderOrganization [0..1] (E_OrganizationUniversal) |
Place |
classCode [1..1] (M) Entity (CS) {CNE:PLC, default= "PLC"} |
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} |
name [0..1] Entity (EN) |
addr [0..1] Place (AD) |