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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)