Transaction: Epidemiological study
General information
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2002-10-15
DEFINITION:
This transaction is used to transfer epidemiological data.
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2002-10-15
DEFINITION:
This transaction is used to transfer epidemiological data.
Guidelines
Generalities
This transaction must, at least, be compliant with the KMEHR level 1. Other levels can be used at the discretion of the user.
Transaction elements
| Element | Purpose |
|---|---|
|
id |
id of the transaction according to theID-KMEHR convention. |
|
cd |
You must use the value 'epidemiology' from CD-TRANSACTION. You can always add your own local codes. |
|
date |
This is the date of reporting. |
|
time |
This is the time of reporting. |
|
author |
This is the the person assuming the responsibility of the medical content of the letter. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person. |
|
iscomplete |
If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later. |
|
isvalidated |
If this is false, this means that the information has not been validated medically. |
Structure overview
You have the choice between:
- text(s) : to transfer your epidemiologica report as free text,
- lnk(s) : to encapsulate your epidemiological report as a multimedia object (Word document for example),
- heading(s) and/or item(s) : to further structure your epidemiological report.
Headings
We recommend the use of the following headings from CD-HEADING
| Heading | Purpose |
|---|---|
|
history |
Patient's history (antecedents) |
|
clinical |
Clinical investigation (including patient's complaints) |
|
technical |
Technical investigation |
|
assessment |
Current diagnoses and hypotheses |
|
clinicalplan |
Clinical plan of action |
|
technicalplan |
Technical plan of action |
|
treatment |
Proposed treatment |
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.
Items
Most items of CD-ITEM are useful. A few items are more specific for the epidemiological report.
|
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 organisation |
|
|
admissiontype |
type of admission process: (planned admission, emergency, ...) |
|
|
healthissue |
to specify current problem(s), diagnoses, hypotheses but also antecedents. |
|
|
allergy |
allergy |
|
|
adr |
adverse drug reaction |
|
|
vaccine |
vaccine administration |
|
|
medication |
pharmaceutical treatment |
|
|
treatment |
treatment other than pharmaceutical |
|
|
habits |
usage of alcohol, tobacco, drug, ... |
|
|
complaint |
patient's complaint |
|
|
clinical |
results of clinical investigations |
|
|
technical |
results of technical investigations |
|
|
risk factor |
like communicable disease, work hazard, ... |
|
|
socialrisk |
like unemployed, junky, ... |
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.
Generalities
This transaction must, at least, be compliant with the KMEHR level 1. Other levels can be used at the discretion of the user.
Transaction elements
| Element | Purpose |
|---|---|
|
id |
id of the transaction according to theID-KMEHR convention. |
|
cd |
You must use the value 'epidemiology' from CD-TRANSACTION. You can always add your own local codes. |
|
date |
This is the date of reporting. |
|
time |
This is the time of reporting. |
|
author |
This is the the person assuming the responsibility of the medical content of the letter. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person. |
|
iscomplete |
If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later. |
|
isvalidated |
If this is false, this means that the information has not been validated medically. |
Structure overview
You have the choice between:
- text(s) : to transfer your epidemiologica report as free text,
- lnk(s) : to encapsulate your epidemiological report as a multimedia object (Word document for example),
- heading(s) and/or item(s) : to further structure your epidemiological report.
Headings
We recommend the use of the following headings from CD-HEADING
| Heading | Purpose |
|---|---|
|
history |
Patient's history (antecedents) |
|
clinical |
Clinical investigation (including patient's complaints) |
|
technical |
Technical investigation |
|
assessment |
Current diagnoses and hypotheses |
|
clinicalplan |
Clinical plan of action |
|
technicalplan |
Technical plan of action |
|
treatment |
Proposed treatment |
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.
Items
Most items of CD-ITEM are useful. A few items are more specific for the epidemiological report.
|
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 organisation |
|
|
admissiontype |
type of admission process: (planned admission, emergency, ...) |
|
|
healthissue |
to specify current problem(s), diagnoses, hypotheses but also antecedents. |
|
|
allergy |
allergy |
|
|
adr |
adverse drug reaction |
|
|
vaccine |
vaccine administration |
|
|
medication |
pharmaceutical treatment |
|
|
treatment |
treatment other than pharmaceutical |
|
|
habits |
usage of alcohol, tobacco, drug, ... |
|
|
complaint |
patient's complaint |
|
|
clinical |
results of clinical investigations |
|
|
technical |
results of technical investigations |
|
|
risk factor |
like communicable disease, work hazard, ... |
|
|
socialrisk |
like unemployed, junky, ... |
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.