The contact report documents a consultation, emergency visit, a home visit...
This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).
You must use the value ‘contactreport’ from CD-TRANSACTION. You can always add your own local codes.
This is the date of the last update of the summary.
This is the time of the last update of the summary.
This is the person assuming the responsibility of the medical content of the record. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person. It must contain the ID-HCPARTY of this healthcare professional and it should contain its INSS number.
Expresses if the summary is completed.
Expresses if the summary is validated.
You have the choice between:
- text(s) : to transfer your contact report as free text,
- lnk(s) : to encapsulate your contact report as a multimedia object (Word document for example),
- heading(s) and/or item(s) : to further structure your contact report.
We recommend the use of the following headings from CD-HEADING.
|history||Patient's history (antecedents)|
|assessment||Current diagnoses and hypotheses|
|clinicalplan||Clinical plan of action|
|technicalplan||Technical plan of action|
Each heading can contain:
- text(s) : to transfer your paragraph as free text,
- lnk(s) : to encapsulate your paragraph as a multimedia object (Word document for example),
- item(s): to further structure your paragraph.
Most items of CD-ITEM are useful.
|Item type (cd)||Item purpose||Item structure|
|encounternumber||your local admission number||Any national standard dictionary could be used to code the content of the items but at this stage of the specification, we recommend to transfer the content of the items as free text.|
|encountertype||hospitalisation, emergency, etc ...|
|encounterdatetime||admission date and time|
|encounterlocation||to document institution, site, unit, room and bed|
|encounterresponsible||responsible of the encounter (can be used to identify the individual and/or the medical department in charge of the patient)|
|transactionreason||reason for admission|
|encounterorigin||origin of the patient before admission (ambulance, home, ...)|
|referrer||the type of entity that referred the patient to the organisatio|
|admissiontype||type of admission process: (planned admission, emergency, ...)|
|dischargedatetime||date and time of the death|
|dischargetype||the type of discharge|
|dischargedestination||the destination after discharge|
|healthissue||to specify current problem(s), diagnoses, hypotheses but also antecedents.|
|adr||adverse drug reaction|
|treatment||treatment other than pharmaceutical|
|habits||usage of alcohol, tobacco, drug, ...|
|clinical||results of clinical investigations|
|technical||results of technical investigations|
|risk factor||like communicable disease, work hazard, ...|
|socialrisk||like unemployed, junky, ...|