| RCMR_MT000002UV01 | This RMIM is used to derive Medical Records speciications. Derived from RMIM: RCMR_RM000030 and HMD: RCMR_HD000030UV01 | ||||||||
| 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) | |||||||||