CONSUMER ENTERED ENCOUNTER Interaction | |||||||||
Data Source | Conceptual Data Item | Logical Data Item | Logical Data Item Description | Logical Data Item Code | Logical Data Item Field Type | ValueSet Value | ValueSet Code & Description | Format | Cardinality |
Harmonised (H) or Operational (Op) | BOLD equals Harmonised data | Name of the Data Item | The description of the logical data item | SNOMED Code and description or FHIR (if handled by FHIR values) | Eg text, date | BOLD equals Harmonised data | eg. SNOMED, LOINC | Format and Example | Relationship of x to y eg IHI is 1..2 |
OP | Date | Date | Date observation was recorded | FHIR / System generated | Date DDMMYYYY | Date | 0..1 | ||
OP | Identity Identifier (Baby, Pregnant Woman/Mother, Parental Responsibility) | IHI | The numerical identifier that uniquely identifies each individual in the Australian healthcare system. | FHIR | Numeric | Numeric | 1..1 | ||
DOB | The date of birth of the person | FHIR | Date | Date | 1..1 | ||||
First Name | First Name of individual | FHIR | Text | Text | 1..1 | ||||
Last Name | Last Name of individual | FHIR | Text | Text | 1..1 | ||||
Sex | Sex used to identify the patient against the HI Service (Administrative Gender - Possibly) | FHIR | Text | Text | 1..1 | ||||
OP | Age | Age | Age of Child when health event was created | System Generated | Date | Date | 0..1 | ||
OP | Encounter | Encounter | An encounter is considered a type of clinical event | SNOMED 1379221000168109 | Reason for encounter | Value Set | Illness | SNOMED 39104002 | Illness | Text | 0..1 |
Surgery | SNOMED 387713003 | Surgical procedure | ||||||||
Injury | SNOMED 417163006 | Traumatic AND/OR non-traumatic injury | ||||||||
Allergy | SNOMED 419076005 | Allergic reaction | ||||||||
Other | Other type of encounter | Text | Text | 0..* | |||||
OP | Comments | Comments | Additional comments | Text | Text | 0..1 | |||
H | Examiner (Person who is clinically responsible for the undetaking of the exam) | First Name | First Name of Examiner | Derived from other information sources / systems | Text | Text | 0..1 | ||
Last Name | Last Name of Examiner | Derived from other information sources / systems | Text | Text | 0..1 | ||||
Designation | The designation of the professional completing the examination | SNOMED 223366009 | Healthcare professional (occupation) (Derived from other information sources / systems) | Text | Text | 0..1 | ||||
Venue | Venue of where examination/assessmment took place | Derived from other information sources / systems | Text | Text | 0..1 | ||||
Op | Interaction Type | Interaction Type | This will be used to identify the health interaction type | FHIR | Text | 1..1 | |||
Op | Attestor (Person who clinically signed off the data) | Attestor | Used to indicate the person who has attested the information is correct | FHIR | HPI-O Name of author | Text | 1..1 | ||
Date and Time | Date and Time of Examiner attesting the information | FHIR | Date (YYYY-MM-DD) Time (HH-MM-SS) | Date | 0..1 | ||||
Op | Author | Author | Used to indicate where the information has been sent from ie System | FHIR | Text | 1..1 |