Transaction: Note
General information
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2002-10-15
DEFINITION:
This type of transaction could be used for free notes, certificates, ...
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2002-10-15
DEFINITION:
This type of transaction could be used for free notes, certificates, ...
Guidelines
Generalities
This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).
Transaction elements
| Element | Purpose |
|---|---|
|
id |
id of the transaction according to the ID-KMEHR conventions. |
|
cd |
You must use the value ‘note’ 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 person assuming the responsibility of medical content of the note. |
|
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 note as free text,
- lnk(s): to encapsulate your note as a multimedia object (Word document for example),
- heading(s) and/or item(s): to further structure your note.
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 note.
|
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, ...) |
|
|
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. |
|
|
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, ... |
Generalities
This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).
Transaction elements
| Element | Purpose |
|---|---|
|
id |
id of the transaction according to the ID-KMEHR conventions. |
|
cd |
You must use the value ‘note’ 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 person assuming the responsibility of medical content of the note. |
|
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 note as free text,
- lnk(s): to encapsulate your note as a multimedia object (Word document for example),
- heading(s) and/or item(s): to further structure your note.
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 note.
|
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, ...) |
|
|
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. |
|
|
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, ... |