STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

??.?? 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 Summaryfor src make thing as tgt = create(Composition), tgt.code = concept("LOINC", "60591-5")
... subjectofCare 1..1Reference(Patient)Subject of Carefor src.subjectofCare as x make tgt.subject = x
... documentAuthor 1..1Reference(Patient | Practitioner | RelatedPerson | Device)Document Authorfor src.documentAuthor as x make tgt.author = x for src.documentAuthor as xa make tgt.attestor as y = x, y.party = xa
... documentType 1..1IdentifierDocument Typefor srcdocumentType make tgt.identifier then by type
... dateTimeAttested 1..1dateTimeDateTime Attestedfor src.dateTimeAttested as x make tgt.date = x
... adverseReactions 1..1ElementAdverse Reactionsfor src.adverseReactions as ar make tgt.section as sct1, sct1.title = "Adverse Reactions", sct1.code= concept("nehta-sct" : "101.20113")
.... exclusionStatementAdverseReactions 0..1ElementExclusion Statement - Adverse Reactionsfor ar.exclusionStatementAdverseReactions as arex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for arex as x make sct1.emptyReason = x
.... adverseReaction 0..*ElementAdverse Reactionfor ar.adverseReasion make ai as ai = create("AllergyIntolerance"), sct1.entry = pointer(ai)
..... substanceAgent 1..1CodeableConceptSubstance/Agent
SubstanceAgentValues (Preferred)		for ai.substanceAgent as x make ai.substance = x
..... event 0..1ElementReaction Eventfor ai.event as ev make ai.reaction as air then by vars
...... manifestation 1..*CodeableConceptManifestation
ClinicalManifestationValues (Preferred)		for ev.manifestation as x make air.manifestation = x
...... reactionType 0..1CodeableConceptReaction Typefor ev.reactionType as x make ai.type as x {only-one}
... medicationOrders 1..1ElementMedication Ordersfor src.medicationOrders as mo make tgt.section as sct2, sct2.title = "Medication Orders", sct2.code= concept("nehta-sct" : "101.16146")
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsfor mo.exclusionStatementMedications as moex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for moex as x make sct2.emptyReason = x
.... medicationInstruction 0..*ElementMedication Instructionfor mo.medicationInstruction as moi make ms as ms = create("MedicationStatement"), sct2.entry = pointer(ms)
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		for moi.therapeuticGoodIdentification as x make ms.medicationCodeableConcept = x
..... directions 1..1stringDirectionsfor moi.directions as moid make ms.dosage as msd, msd.text = moid
..... clinicalIndication 0..1stringClinical Indicationfor moi.clinicalIndication as moic make ms.reasonForUseCodeableConcept as ru, ru.text = moic
..... comment 0..1stringMedication Instruction Commentfor moi.comment as x make ms.note = x
... medicalHistory 1..1ElementMedical Historyfor src.medicalHistory as mh make tgt.section as sct3, sct3.title = "Medical History", sct3.code= concept("nehta-sct" : "101.16117")
.... problemDiagnosis 0..*ElementProblem/Diagnosisfor mh.problemDiagnosis as pd make cnd as cnd = create("Condition"), sct3.entry = pointer(cnd)
..... identification 1..1CodeableConceptProblem/Diagnosis Identificationfor pd.identitification as x make cnd.code = x
..... dateofOnset 0..1dateTimeDate of Onsetfor pd.dateOfOnset as x make cnd.onsetDateTime = x
..... dateofResolutionRemission 0..1dateTimeDate of Resolution/Remissionfor pd.dateOfResolutionRemission as x make cnd.abatementDate = x
..... comment 0..1stringProblem/Diagnosis Commentfor pd.comment as x make cnd.notes = x
.... exclusionStatementProblemsandDiagnoses 0..1ElementExclusion Statement - Problems and Diagnosesfor pd.exclusionStatementProblemsandDiagnoses as pdex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for pdex as x make sct3.emptyReason = x
.... procedure 0..*ElementProcedurefor mh.procedure as pr make cndp as cndp = create("Condition"), sct3.entry = pointer(cndp)
..... name 1..1CodeableConceptProcedure Namefor pd.name as x make cndp.code = x
..... comment 0..1stringProcedure Commentfor pd.comment as x make cndp.notes = x
..... dateTime 1..1PeriodProcedure DateTimefor pr.dateTime as x make cndp.onsetDateTime = x
.... exclusionStatementProcedures 0..1ElementExclusion Statement - Proceduresfor mh.exclusionStatementProcedures as prex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for prex as x make sct3.emptyReason = x
.... uncategorisedMedicalHistoryItem 0..*ElementUncategorised Medical History Itemfor mh.uncategorisedMedicalHistoryItem as item make cndi as cndp = create("Condition"), sct3.entry = pointer(cndi) then by vars
..... description 1..1stringMedical History Item Descriptionfor item.description as x make cndi.code as y, y.text = x
..... timeInterval 0..1PeriodMedical History Item TimeIntervalfor item.timeInterval as ti then by vars for ti.start as x make cndi.onsetDateTime = x for ti.end as x make cndi.abatementDate = x
..... comment 0..1stringMedical History Item Commentfor item.comment as x make cndi.notes = x
... immunisations 1..1ElementImmunisationsfor src.immunizations as imm make tgt.section as sct4, sct4.title = "Immunization", sct4.code= concept("nehta-sct", "101.16117)
.... medicationAction 0..*ElementMedication Actionfor imm.medicationAction as ima make im as im = create("Immunization"), sct4.entry = pointer(im)
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		for ima.therapeuticGoodIdentification as x make im.vaccineType = x
..... sequenceNumber 0..1integerSequence Numberfor ima.sequenceNumber as x make im.vaccinationProtocol as vp, vp.doseSequence = x
..... dateTime 1..1dateTimeMedication Action DateTimefor ima.dateTime as x make imm.date = x
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsfor imm.exclusionStatementMedications as imex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for imex as x make sct4.emptyReason = x

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 Summaryfor src make thing as tgt = create(Composition), tgt.code = concept("LOINC", "60591-5")
... subjectofCare 1..1Reference(Patient)Subject of Carefor src.subjectofCare as x make tgt.subject = x
... documentAuthor 1..1Reference(Patient | Practitioner | RelatedPerson | Device)Document Authorfor src.documentAuthor as x make tgt.author = x for src.documentAuthor as xa make tgt.attestor as y = x, y.party = xa
... documentType 1..1IdentifierDocument Typefor srcdocumentType make tgt.identifier then by type
... dateTimeAttested 1..1dateTimeDateTime Attestedfor src.dateTimeAttested as x make tgt.date = x
... adverseReactions 1..1ElementAdverse Reactionsfor src.adverseReactions as ar make tgt.section as sct1, sct1.title = "Adverse Reactions", sct1.code= concept("nehta-sct" : "101.20113")
.... exclusionStatementAdverseReactions 0..1ElementExclusion Statement - Adverse Reactionsfor ar.exclusionStatementAdverseReactions as arex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for arex as x make sct1.emptyReason = x
.... adverseReaction 0..*ElementAdverse Reactionfor ar.adverseReasion make ai as ai = create("AllergyIntolerance"), sct1.entry = pointer(ai)
..... substanceAgent 1..1CodeableConceptSubstance/Agent
SubstanceAgentValues (Preferred)		for ai.substanceAgent as x make ai.substance = x
..... event 0..1ElementReaction Eventfor ai.event as ev make ai.reaction as air then by vars
...... manifestation 1..*CodeableConceptManifestation
ClinicalManifestationValues (Preferred)		for ev.manifestation as x make air.manifestation = x
...... reactionType 0..1CodeableConceptReaction Typefor ev.reactionType as x make ai.type as x {only-one}
... medicationOrders 1..1ElementMedication Ordersfor src.medicationOrders as mo make tgt.section as sct2, sct2.title = "Medication Orders", sct2.code= concept("nehta-sct" : "101.16146")
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsfor mo.exclusionStatementMedications as moex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for moex as x make sct2.emptyReason = x
.... medicationInstruction 0..*ElementMedication Instructionfor mo.medicationInstruction as moi make ms as ms = create("MedicationStatement"), sct2.entry = pointer(ms)
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		for moi.therapeuticGoodIdentification as x make ms.medicationCodeableConcept = x
..... directions 1..1stringDirectionsfor moi.directions as moid make ms.dosage as msd, msd.text = moid
..... clinicalIndication 0..1stringClinical Indicationfor moi.clinicalIndication as moic make ms.reasonForUseCodeableConcept as ru, ru.text = moic
..... comment 0..1stringMedication Instruction Commentfor moi.comment as x make ms.note = x
... medicalHistory 1..1ElementMedical Historyfor src.medicalHistory as mh make tgt.section as sct3, sct3.title = "Medical History", sct3.code= concept("nehta-sct" : "101.16117")
.... problemDiagnosis 0..*ElementProblem/Diagnosisfor mh.problemDiagnosis as pd make cnd as cnd = create("Condition"), sct3.entry = pointer(cnd)
..... identification 1..1CodeableConceptProblem/Diagnosis Identificationfor pd.identitification as x make cnd.code = x
..... dateofOnset 0..1dateTimeDate of Onsetfor pd.dateOfOnset as x make cnd.onsetDateTime = x
..... dateofResolutionRemission 0..1dateTimeDate of Resolution/Remissionfor pd.dateOfResolutionRemission as x make cnd.abatementDate = x
..... comment 0..1stringProblem/Diagnosis Commentfor pd.comment as x make cnd.notes = x
.... exclusionStatementProblemsandDiagnoses 0..1ElementExclusion Statement - Problems and Diagnosesfor pd.exclusionStatementProblemsandDiagnoses as pdex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for pdex as x make sct3.emptyReason = x
.... procedure 0..*ElementProcedurefor mh.procedure as pr make cndp as cndp = create("Condition"), sct3.entry = pointer(cndp)
..... name 1..1CodeableConceptProcedure Namefor pd.name as x make cndp.code = x
..... comment 0..1stringProcedure Commentfor pd.comment as x make cndp.notes = x
..... dateTime 1..1PeriodProcedure DateTimefor pr.dateTime as x make cndp.onsetDateTime = x
.... exclusionStatementProcedures 0..1ElementExclusion Statement - Proceduresfor mh.exclusionStatementProcedures as prex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for prex as x make sct3.emptyReason = x
.... uncategorisedMedicalHistoryItem 0..*ElementUncategorised Medical History Itemfor mh.uncategorisedMedicalHistoryItem as item make cndi as cndp = create("Condition"), sct3.entry = pointer(cndi) then by vars
..... description 1..1stringMedical History Item Descriptionfor item.description as x make cndi.code as y, y.text = x
..... timeInterval 0..1PeriodMedical History Item TimeIntervalfor item.timeInterval as ti then by vars for ti.start as x make cndi.onsetDateTime = x for ti.end as x make cndi.abatementDate = x
..... comment 0..1stringMedical History Item Commentfor item.comment as x make cndi.notes = x
... immunisations 1..1ElementImmunisationsfor src.immunizations as imm make tgt.section as sct4, sct4.title = "Immunization", sct4.code= concept("nehta-sct", "101.16117)
.... medicationAction 0..*ElementMedication Actionfor imm.medicationAction as ima make im as im = create("Immunization"), sct4.entry = pointer(im)
..... therapeuticGoodIdentification 1..1CodeableConceptTherapeutic Good Identification
MedicinesTerminology (Preferred)		for ima.therapeuticGoodIdentification as x make im.vaccineType = x
..... sequenceNumber 0..1integerSequence Numberfor ima.sequenceNumber as x make im.vaccinationProtocol as vp, vp.doseSequence = x
..... dateTime 1..1dateTimeMedication Action DateTimefor ima.dateTime as x make imm.date = x
.... exclusionStatementMedications 0..1ElementExclusion Statement - Medicationsfor imm.exclusionStatementMedications as imex then by vars
..... globalStatement 1..1CodeableConceptGlobal Statement
GlobalStatementValues (Required)		for imex as x make sct4.emptyReason = x

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;