Connectathon 11 Snapshot

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??.?? Logical Model nehta-shared-health-summary - Content

A clinical document written by the nominated provider, which contains key pieces of information about an individual’s health status and is useful to a wide range of providers in assessing individuals and delivering care. (PCEHR Concept of Operations document).

??.??.1 Scope and Usage

This model specifies the clinical data elements to be captured in the exchange of Shared Health Summary documents and the constraints that should be applied. Its scope is aligned to the document Concept of Operations: Relating to the introduction of a Personally Controlled Electronic Health Record System .

??.??.2 Boundaries and Relationships

This is not a guide to implementing any specific messaging standard.

This specification is not to be used as a guide to presentation (or rendering) of the data. It contains no information as to how the data described by it should be displayed and no such information should be inferred.

??.??.3 Background and Context

TOGO

??.??.4 Logical Model Content

Structure

NameFlagsCard.TypeDescription & ConstraintsImplemented Asdoco
.. SharedHealthSummary LogicalShared Health SummaryComposition[code= LOINC:60591-5]
... subjectofCare 1..1Reference(Patient)Subject of CareComposition.subject
... documentAuthor 1..1Reference(Patient | Practitioner | RelatedPerson | Device)Document AuthorComposition.author;Composition.attester.party
... documentType 1..1IdentifierDocument TypeComposition.identifier
... dateTimeAttested 1..1dateTimeDateTime AttestedComposition.date
... adverseReactions 1..1ElementAdverse Reactions@sct1 = Composition.section[title='Adverse Reactions'; code={nehta-sct:101.20113}]
.... exclusionStatementAdverseReactions 0..1ElementExclusion Statement - Adverse Reactionsn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct1.emptyReason
.... adverseReaction 0..*ElementAdverse Reaction@ai = sct1.entry→AllergyIntolerance
..... substanceAgent 1..1CodeableConceptSubstance/Agent
SubstanceAgentValues (Preferred)		ai.substance
..... event 0..1ElementReaction Event@ev = ai.event
...... manifestation 1..*CodeableConceptManifestation
ClinicalManifestationValues (Preferred)		ev.manifestation
...... reactionType 0..1CodeableConceptReaction Typeai.type
... medicationOrders 1..1ElementMedication Orders@sct2 = Composition.section[title='Medication Orders'; code={nehta-sct:101.16146}]
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct2.emptyReason
.... medicationInstruction 0..*ElementMedication Instruction@ms = sct2.entry→MedicationStatement
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		ms.medicationCodeableConcept
..... directions 1..1stringDirectionsms.dosage.text
..... clinicalIndication 0..1stringClinical Indicationms.reasonForUseCodeableConcept.text
..... comment 0..1stringMedication Instruction Commentms.note
... medicalHistory 1..1ElementMedical History@sct3 = Composition.section[title='Medical History'; code={nehta-sct:101.16117}]
.... problemDiagnosis 0..*ElementProblem/Diagnosis@cnd1 = sct3.entry→Condition
..... identification 1..1CodeableConceptProblem/Diagnosis Identificationcnd1.code
..... dateofOnset 0..1dateTimeDate of Onsetcnd1.onsetDateTime
..... dateofResolutionRemission 0..1dateTimeDate of Resolution/Remissioncnd1.abatementDate
..... comment 0..1stringProblem/Diagnosis Commentcnd1.notes
.... exclusionStatementProblemsandDiagnoses 0..1ElementExclusion Statement - Problems and Diagnosesn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct3.emptyReason
.... procedure 0..*ElementProcedure@cnd2 = sct3.entry→Condition
..... name 1..1CodeableConceptProcedure Namecnd2.code
..... comment 0..1stringProcedure Commentcnd2.notes
..... dateTime 1..1PeriodProcedure DateTimecnd2.onsetDateTime
.... exclusionStatementProcedures 0..1ElementExclusion Statement - Proceduresn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct3.emptyReason
.... uncategorisedMedicalHistoryItem 0..*ElementUncategorised Medical History Item@cnd3 = sct3.entry→Condition
..... description 1..1stringMedical History Item Descriptioncnd3.code.text
..... timeInterval 0..1PeriodMedical History Item TimeIntervalcnd3.onsetDateTime & cnd3.abatementDate
..... comment 0..1stringMedical History Item Commentcnd3.notes
... immunisations 1..1ElementImmunisations@sct4 = Composition.section[title='Immunization'; code={nehta-sct:101.16117}]
.... medicationAction 0..*ElementMedication Action@imm = sct4.entry→Immunization
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		imm.vaccineType
..... sequenceNumber 0..1integerSequence Numberimm.vaccinationProtocol.doseSequence
..... dateTime 1..1dateTimeMedication Action DateTimeimm.date
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct4.emptyReason

doco Documentation for this format

UML Diagram

SharedHealthSummary (Logical)Person who receives healthcare servicessubjectofCare : Reference [1..1] « Patient »Composer of the documentdocumentAuthor : Reference [1..1] « Patient|Practitioner| RelatedPerson|Device »Type of documentdocumentType : Identifier [1..1]The date and time that the document author or document authoriser or approver confirms that a document is complete and genuinedateTimeAttested : dateTime [1..1]AdverseReactionsExclusionStatementAdverseReactionsThe statement about the absence or exclusionglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »AdverseReactionIdentification of a substance, agent, or a class of substance, that is considered to be responsible for the adverse reactionsubstanceAgent : CodeableConcept [1..1] « The set of values for the agent or substance causing the adverse reaction experienced by the subject of care. (Strength=Preferred)SubstanceAgentValues? »EventPresentation or exhibition of signs and symptoms of the adverse reaction expressed as a single word, phrase or brief descriptionmanifestation : CodeableConcept [1..*] « The set of values for recording clinical manifestation of an adverse reaction. (Strength=Preferred)ClinicalManifestationValues? »The type of reaction, as determined by the clinicianreactionType : CodeableConcept [0..1]MedicationOrdersExclusionStatementMedicationsThe statement about the absence or exclusion of certain medicationglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »MedicationInstructionThe medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of caretherapeuticGoodIdentification : CodeableConcept [1..1] « A set of values used to refer to medicines and other therapeutic goods. (Strength=Preferred) MedicinesTerminology? »A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic gooddirections : string [1..1]Reason for ordering the medicine, vaccine or other therapeutic goodclinicalIndication : string [0..1]Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate usecomment : string [0..1]MedicalHistoryProblemDiagnosisIdentification of the problem or diagnosisidentification : CodeableConcept [1..1]Estimated or actual date the problem or diagnosis began, as indicated or identified by the cliniciandateofOnset : dateTime [0..1]Estimated or actual date the problem or diagnosis resolved or went into remission, as indicated or identified by the cliniciandateofResolutionRemission : dateTime [0..1]Additional narrative about the problem or diagnosis not captured in other fieldscomment : string [0..1]ExclusionStatementProblemsandDiagnosesThe statement about the absence or exclusionglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »ProcedureThe name of the procedure (to be) performedname : CodeableConcept [1..1]Additional narrative about the procedure not captured in other fieldscomment : string [0..1]Date, and optionally time, of the Procedure actiondateTime : Period [1..1]ExclusionStatementProceduresThe statement about the absence or exclusion of procedure performed on the patientglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »UncategorisedMedicalHistoryItemA description of the problem, diagnosis or procedure as a medical history itemdescription : string [1..1]The date range during which the problem or diagnosis applied or the procedure occurredtimeInterval : Period [0..1]Additional narrative about the problem, diagnosis or procedurecomment : string [0..1]ImmunisationsMedicationActionThe medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of caretherapeuticGoodIdentification : CodeableConcept [1..1] « A set of values used to refer to medicines and other therapeutic goods. (Strength=Preferred) MedicinesTerminology? »The sequence number specific to the action being recordedsequenceNumber : integer [0..1]Date, and optionally time, that the medication action is completeddateTime : dateTime [1..1]ExclusionStatementMedicationsThe statement about the absence or exclusion of certain medicationglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »Statements about adverse reactions that need to be positively recorded as absent or excludedexclusionStatementAdverseReactions[0..1]Details about each adverse reaction eventevent[0..1]A harmful or undesirable effect associated with exposure to any substance or agentadverseReaction[0..*]Information about adverse reactions of the patient (including allergies and intolerances), and any relevant reaction details. This includes statements about adverse reactions that need to be positively recorded as absent or excludedadverseReactions[1..1]Statement to positively assert that the patient has not been prescribed or is not taking certain medicationexclusionStatementMedications[0..1]Information pertaining to one or more therapeutic goods that is represented to achieve, or is likely to achieve, its principal intended action by pharmacological, chemical, immunological or metabolic means in or on the body of a humanmedicationInstruction[0..*]Medicines that the subject of care is usingmedicationOrders[1..1]A health condition that, as determined by a clinician, may have impact on the physical, mental or social well-being of a person. A diagnosis is determined by scientific evaluation of pathological and pathophysiological findings identified from the patient's clinical history, family history, physical examination and diagnostic investigationsproblemDiagnosis[0..*]Statements which positively assert that the patient does not have the problem or diagnosisexclusionStatementProblemsandDiagnoses[0..1]A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposesprocedure[0..*]Statements to positively assert that a certain procedure has not been performed on the patientexclusionStatementProcedures[0..1]A medical history entry that has not been categorised as either Procedure or Problem/Diagnosis uncategorisedMedicalHistoryItem[0..*]The history of the subject of care's problems, diagnoses and medical or surgical proceduresmedicalHistory[1..1]The act of administering a dose of a vaccine to a person for the purpose of preventing or minimising the effects of a disease by producing immunity or to counter the effects of an infectious organismmedicationAction[0..*]Statements that positively assert that the patient has not received immunisationsexclusionStatementMedications[0..1]Information about vaccines given to the subject of careimmunisations[1..1]

Structure

NameFlagsCard.TypeDescription & ConstraintsImplemented Asdoco
.. SharedHealthSummary LogicalShared Health SummaryComposition[code= LOINC:60591-5]
... subjectofCare 1..1Reference(Patient)Subject of CareComposition.subject
... documentAuthor 1..1Reference(Patient | Practitioner | RelatedPerson | Device)Document AuthorComposition.author;Composition.attester.party
... documentType 1..1IdentifierDocument TypeComposition.identifier
... dateTimeAttested 1..1dateTimeDateTime AttestedComposition.date
... adverseReactions 1..1ElementAdverse Reactions@sct1 = Composition.section[title='Adverse Reactions'; code={nehta-sct:101.20113}]
.... exclusionStatementAdverseReactions 0..1ElementExclusion Statement - Adverse Reactionsn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct1.emptyReason
.... adverseReaction 0..*ElementAdverse Reaction@ai = sct1.entry→AllergyIntolerance
..... substanceAgent 1..1CodeableConceptSubstance/Agent
SubstanceAgentValues (Preferred)		ai.substance
..... event 0..1ElementReaction Event@ev = ai.event
...... manifestation 1..*CodeableConceptManifestation
ClinicalManifestationValues (Preferred)		ev.manifestation
...... reactionType 0..1CodeableConceptReaction Typeai.type
... medicationOrders 1..1ElementMedication Orders@sct2 = Composition.section[title='Medication Orders'; code={nehta-sct:101.16146}]
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct2.emptyReason
.... medicationInstruction 0..*ElementMedication Instruction@ms = sct2.entry→MedicationStatement
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		ms.medicationCodeableConcept
..... directions 1..1stringDirectionsms.dosage.text
..... clinicalIndication 0..1stringClinical Indicationms.reasonForUseCodeableConcept.text
..... comment 0..1stringMedication Instruction Commentms.note
... medicalHistory 1..1ElementMedical History@sct3 = Composition.section[title='Medical History'; code={nehta-sct:101.16117}]
.... problemDiagnosis 0..*ElementProblem/Diagnosis@cnd1 = sct3.entry→Condition
..... identification 1..1CodeableConceptProblem/Diagnosis Identificationcnd1.code
..... dateofOnset 0..1dateTimeDate of Onsetcnd1.onsetDateTime
..... dateofResolutionRemission 0..1dateTimeDate of Resolution/Remissioncnd1.abatementDate
..... comment 0..1stringProblem/Diagnosis Commentcnd1.notes
.... exclusionStatementProblemsandDiagnoses 0..1ElementExclusion Statement - Problems and Diagnosesn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct3.emptyReason
.... procedure 0..*ElementProcedure@cnd2 = sct3.entry→Condition
..... name 1..1CodeableConceptProcedure Namecnd2.code
..... comment 0..1stringProcedure Commentcnd2.notes
..... dateTime 1..1PeriodProcedure DateTimecnd2.onsetDateTime
.... exclusionStatementProcedures 0..1ElementExclusion Statement - Proceduresn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct3.emptyReason
.... uncategorisedMedicalHistoryItem 0..*ElementUncategorised Medical History Item@cnd3 = sct3.entry→Condition
..... description 1..1stringMedical History Item Descriptioncnd3.code.text
..... timeInterval 0..1PeriodMedical History Item TimeIntervalcnd3.onsetDateTime & cnd3.abatementDate
..... comment 0..1stringMedical History Item Commentcnd3.notes
... immunisations 1..1ElementImmunisations@sct4 = Composition.section[title='Immunization'; code={nehta-sct:101.16117}]
.... medicationAction 0..*ElementMedication Action@imm = sct4.entry→Immunization
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		imm.vaccineType
..... sequenceNumber 0..1integerSequence Numberimm.vaccinationProtocol.doseSequence
..... dateTime 1..1dateTimeMedication Action DateTimeimm.date
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsn/a
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		sct4.emptyReason

doco Documentation for this format

UML Diagram

SharedHealthSummary (Logical)Person who receives healthcare servicessubjectofCare : Reference [1..1] « Patient »Composer of the documentdocumentAuthor : Reference [1..1] « Patient|Practitioner| RelatedPerson|Device »Type of documentdocumentType : Identifier [1..1]The date and time that the document author or document authoriser or approver confirms that a document is complete and genuinedateTimeAttested : dateTime [1..1]AdverseReactionsExclusionStatementAdverseReactionsThe statement about the absence or exclusionglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »AdverseReactionIdentification of a substance, agent, or a class of substance, that is considered to be responsible for the adverse reactionsubstanceAgent : CodeableConcept [1..1] « The set of values for the agent or substance causing the adverse reaction experienced by the subject of care. (Strength=Preferred)SubstanceAgentValues? »EventPresentation or exhibition of signs and symptoms of the adverse reaction expressed as a single word, phrase or brief descriptionmanifestation : CodeableConcept [1..*] « The set of values for recording clinical manifestation of an adverse reaction. (Strength=Preferred)ClinicalManifestationValues? »The type of reaction, as determined by the clinicianreactionType : CodeableConcept [0..1]MedicationOrdersExclusionStatementMedicationsThe statement about the absence or exclusion of certain medicationglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »MedicationInstructionThe medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of caretherapeuticGoodIdentification : CodeableConcept [1..1] « A set of values used to refer to medicines and other therapeutic goods. (Strength=Preferred) MedicinesTerminology? »A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic gooddirections : string [1..1]Reason for ordering the medicine, vaccine or other therapeutic goodclinicalIndication : string [0..1]Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate usecomment : string [0..1]MedicalHistoryProblemDiagnosisIdentification of the problem or diagnosisidentification : CodeableConcept [1..1]Estimated or actual date the problem or diagnosis began, as indicated or identified by the cliniciandateofOnset : dateTime [0..1]Estimated or actual date the problem or diagnosis resolved or went into remission, as indicated or identified by the cliniciandateofResolutionRemission : dateTime [0..1]Additional narrative about the problem or diagnosis not captured in other fieldscomment : string [0..1]ExclusionStatementProblemsandDiagnosesThe statement about the absence or exclusionglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »ProcedureThe name of the procedure (to be) performedname : CodeableConcept [1..1]Additional narrative about the procedure not captured in other fieldscomment : string [0..1]Date, and optionally time, of the Procedure actiondateTime : Period [1..1]ExclusionStatementProceduresThe statement about the absence or exclusion of procedure performed on the patientglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »UncategorisedMedicalHistoryItemA description of the problem, diagnosis or procedure as a medical history itemdescription : string [1..1]The date range during which the problem or diagnosis applied or the procedure occurredtimeInterval : Period [0..1]Additional narrative about the problem, diagnosis or procedurecomment : string [0..1]ImmunisationsMedicationActionThe medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of caretherapeuticGoodIdentification : CodeableConcept [1..1] « A set of values used to refer to medicines and other therapeutic goods. (Strength=Preferred) MedicinesTerminology? »The sequence number specific to the action being recordedsequenceNumber : integer [0..1]Date, and optionally time, that the medication action is completeddateTime : dateTime [1..1]ExclusionStatementMedicationsThe statement about the absence or exclusion of certain medicationglobalStatement : CodeableConcept [1..1] « The set of values for the global statements about the exclusion. (Strength=Required)GlobalStatementValues! »Statements about adverse reactions that need to be positively recorded as absent or excludedexclusionStatementAdverseReactions[0..1]Details about each adverse reaction eventevent[0..1]A harmful or undesirable effect associated with exposure to any substance or agentadverseReaction[0..*]Information about adverse reactions of the patient (including allergies and intolerances), and any relevant reaction details. This includes statements about adverse reactions that need to be positively recorded as absent or excludedadverseReactions[1..1]Statement to positively assert that the patient has not been prescribed or is not taking certain medicationexclusionStatementMedications[0..1]Information pertaining to one or more therapeutic goods that is represented to achieve, or is likely to achieve, its principal intended action by pharmacological, chemical, immunological or metabolic means in or on the body of a humanmedicationInstruction[0..*]Medicines that the subject of care is usingmedicationOrders[1..1]A health condition that, as determined by a clinician, may have impact on the physical, mental or social well-being of a person. A diagnosis is determined by scientific evaluation of pathological and pathophysiological findings identified from the patient's clinical history, family history, physical examination and diagnostic investigationsproblemDiagnosis[0..*]Statements which positively assert that the patient does not have the problem or diagnosisexclusionStatementProblemsandDiagnoses[0..1]A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposesprocedure[0..*]Statements to positively assert that a certain procedure has not been performed on the patientexclusionStatementProcedures[0..1]A medical history entry that has not been categorised as either Procedure or Problem/Diagnosis uncategorisedMedicalHistoryItem[0..*]The history of the subject of care's problems, diagnoses and medical or surgical proceduresmedicalHistory[1..1]The act of administering a dose of a vaccine to a person for the purpose of preventing or minimising the effects of a disease by producing immunity or to counter the effects of an infectious organismmedicationAction[0..*]Statements that positively assert that the patient has not received immunisationsexclusionStatementMedications[0..1]Information about vaccines given to the subject of careimmunisations[1..1]

 

??.??.4.1 Terminology Bindings

PathDefinitionTypeReference
SharedHealthSummary.adverseReactions.exclusionStatementAdverseReactions.globalStatement
SharedHealthSummary.medicationOrders.exclusionStatementMedications.globalStatement
SharedHealthSummary.medicalHistory.exclusionStatementProblemsandDiagnoses.globalStatement
SharedHealthSummary.medicalHistory.exclusionStatementProcedures.globalStatement
SharedHealthSummary.immunisations.exclusionStatementMedications.globalStatement 		The set of values for the global statements about the exclusion.RequiredGlobalStatementValues
SharedHealthSummary.adverseReactions.adverseReaction.substanceAgent The set of values for the agent or substance causing the adverse reaction experienced by the subject of care.PreferredSubstanceAgentValues
SharedHealthSummary.adverseReactions.adverseReaction.event.manifestation The set of values for recording clinical manifestation of an adverse reaction.PreferredClinicalManifestationValues
SharedHealthSummary.adverseReactions.adverseReaction.event.reactionType The set of values for the type of adverse reaction.UnknownNo details provided yet
SharedHealthSummary.medicationOrders.medicationInstruction.therapeuticGoodIdentification
SharedHealthSummary.immunisations.medicationAction.therapeuticGoodIdentification 		A set of values used to refer to medicines and other therapeutic goods.PreferredMedicinesTerminology
SharedHealthSummary.medicalHistory.problemDiagnosis.identification The Problem/Diagnosis reference set provides terminology to support the recording of a subject of care problem or diagnosis for medical records within Australia.UnknownNo details provided yet
SharedHealthSummary.medicalHistory.procedure.name The Procedure foundation reference set provides the broadest possible terminology to support the recording of clinical interventions in Australian eHealth implementations.UnknownNo details provided yet

??.??.5 Notes:

todo;