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).

Person who receives healthcare services.

Composer of the document.

Type of document.

The date and time that the document author or document authoriser or approver confirms that a document is complete and genuine.

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 excluded.

Statements about adverse reactions that need to be positively recorded as absent or excluded.

The statement about the absence or exclusion.

A harmful or undesirable effect associated with exposure to any substance or agent.

Identification of a substance, agent, or a class of substance, that is considered to be responsible for the adverse reaction.

Details about each adverse reaction event.

Presentation or exhibition of signs and symptoms of the adverse reaction expressed as a single word, phrase or brief description.

The type of reaction, as determined by the clinician.

Medicines that the subject of care is using.

Statement to positively assert that the patient has not been prescribed or is not taking certain medication.

The statement about the absence or exclusion of certain medication.

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 human.

The medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of care.

A complete narrative description of how much, when and how to use the medicine, vaccine or other therapeutic good.

Reason for ordering the medicine, vaccine or other therapeutic good.

Any additional information that may be needed to ensure the continuity of supply, rationale for current dose and timing, or safe and appropriate use.

The history of the subject of care's problems, diagnoses and medical or surgical procedures.

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 investigations.

Identification of the problem or diagnosis.

Estimated or actual date the problem or diagnosis began, as indicated or identified by the clinician.

Estimated or actual date the problem or diagnosis resolved or went into remission, as indicated or identified by the clinician.

Additional narrative about the problem or diagnosis not captured in other fields.

Statements which positively assert that the patient does not have the problem or diagnosis.

The statement about the absence or exclusion.

A clinical activity carried out for therapeutic, evaluative, investigative, screening or diagnostic purposes.

The name of the procedure (to be) performed.

Additional narrative about the procedure not captured in other fields.

Date, and optionally time, of the Procedure action.

Statements to positively assert that a certain procedure has not been performed on the patient.

The statement about the absence or exclusion of procedure performed on the patient.

A medical history entry that has not been categorised as either Procedure or Problem/Diagnosis .

A description of the problem, diagnosis or procedure as a medical history item.

The date range during which the problem or diagnosis applied or the procedure occurred.

Additional narrative about the problem, diagnosis or procedure.

Information about vaccines given to the subject of care.

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 organism.

The medicine, vaccine or other therapeutic good being ordered for, administered to or used by the subject of care.

The sequence number specific to the action being recorded.

Date, and optionally time, that the medication action is completed.

Statements that positively assert that the patient has not received immunisations.

The statement about the absence or exclusion of certain medication.