This page is part of the FHIR Specification (v4.2.0: R5 Preview #1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3
Patient Care Work Group | Maturity Level: 0 | Trial Use | Security Category: Patient | Compartments: Patient, Practitioner, RelatedPerson |
Detailed Descriptions for the elements in the AdverseEvent resource.
AdverseEvent | |
Element Id | AdverseEvent |
Definition | An event (i.e. any change to current patient status) that may be related to unintended effects on a patient or research subject. The unintended effects may require additional monitoring, treatment or hospitalization or may result in death. The AdverseEvent resource also extends to potential or avoided events that could have had such effects. |
Cardinality | 0..* |
Type | DomainResource |
Alternate Names | AE |
Summary | true |
AdverseEvent.identifier | |
Element Id | AdverseEvent.identifier |
Definition | Business identifiers assigned to this adverse event by the performer or other systems which remain constant as the resource is updated and propagates from server to server. |
Note | This is a business identifier, not a resource identifier (see discussion) |
Cardinality | 0..* |
Type | Identifier |
Requirements | Allows identification of the adverse event as it is known by various participating systems and in a way that remains consistent across servers. |
Summary | true |
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. |
AdverseEvent.status | |
Element Id | AdverseEvent.status |
Definition | The current state of the data entry of the adverse event or potential adverse event. |
Cardinality | 1..1 |
Terminology Binding | Adverse Event Status (Required) |
Type | code |
Is Modifier | true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid) |
Summary | true |
Comments | This is not the reporting of the event to any regulatory or quality organization. |
AdverseEvent.actuality | |
Element Id | AdverseEvent.actuality |
Definition | Whether the event actually happened, or just had the potential to. Note that this is independent of whether anyone was affected or harmed or how severely. |
Cardinality | 1..1 |
Terminology Binding | AdverseEventActuality (Required) |
Type | code |
Is Modifier | true (Reason: This element is labeled as a modifier because it has a potential code that indicates the adverse event did not actually happen.) |
Summary | true |
AdverseEvent.category | |
Element Id | AdverseEvent.category |
Definition | The overall type of event, intended for search and filtering purposes. |
Cardinality | 0..* |
Terminology Binding | AdverseEventCategory (Extensible) |
Type | CodeableConcept |
Summary | true |
AdverseEvent.code | |
Element Id | AdverseEvent.code |
Definition | Specific event that occurred or that was averted, such as patient fall, wrong organ removed, or wrong blood transfused. |
Cardinality | 0..1 |
Terminology Binding | AdverseEvent Type (Example) |
Type | CodeableConcept |
Summary | true |
AdverseEvent.subject | |
Element Id | AdverseEvent.subject |
Definition | This subject or group impacted by the event. |
Cardinality | 1..1 |
Type | Reference(Patient | Group | Practitioner | RelatedPerson) |
Patterns | Reference(Patient,Group,Practitioner,RelatedPerson): Common patterns = Participant |
Requirements | Allows for exposure of biohazard (such as legionella) to a group of individuals in a hospital. |
Alternate Names | patient |
Summary | true |
Comments | If AdverseEvent.resultingCondition differs among members of the group, then use Patient as the subject. |
AdverseEvent.encounter | |
Element Id | AdverseEvent.encounter |
Definition | The Encounter during which AdverseEvent was created or to which the creation of this record is tightly associated. |
Cardinality | 0..1 |
Type | Reference(Encounter) |
Summary | true |
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. For example, if a medication administration was considered an adverse event because it resulted in a rash, then the encounter when the medication administration was given is the context. If the patient reports the AdverseEvent during a second encounter, that second encounter is not the context. |
AdverseEvent.occurrence[x] | |
Element Id | AdverseEvent.occurrence[x] |
Definition | The date (and perhaps time) when the adverse event occurred. |
Cardinality | 0..1 |
Type | dateTime|Period|Timing |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Alternate Names | timing |
Summary | true |
AdverseEvent.detected | |
Element Id | AdverseEvent.detected |
Definition | Estimated or actual date the AdverseEvent began, in the opinion of the reporter. |
Cardinality | 0..1 |
Type | dateTime |
Summary | true |
AdverseEvent.recordedDate | |
Element Id | AdverseEvent.recordedDate |
Definition | The date on which the existence of the AdverseEvent was first recorded. |
Cardinality | 0..1 |
Type | dateTime |
Summary | true |
Comments | The recordedDate represents the date when this particular AdverseEvent record was created in the system, not the date of the most recent update. The date of the last record modification can be retrieved from the resource metadata. |
AdverseEvent.resultingCondition | |
Element Id | AdverseEvent.resultingCondition |
Definition | Includes information about the reaction that occurred as a result of exposure to a substance (for example, a drug or a chemical). |
Cardinality | 0..* |
Type | Reference(Condition) |
Summary | true |
AdverseEvent.location | |
Element Id | AdverseEvent.location |
Definition | The information about where the adverse event occurred. |
Cardinality | 0..1 |
Type | Reference(Location) |
Summary | true |
AdverseEvent.seriousness | |
Element Id | AdverseEvent.seriousness |
Definition | Assessment whether this event, or averted event, was of clinical importance. |
Cardinality | 0..1 |
Terminology Binding | AdverseEventSeriousness (Example) |
Type | CodeableConcept |
Summary | true |
Comments | Using an example, a rash can have an AdverseEvent.resultingCondition.severity = severe, yet an AdverseEvent.seriousness = non-serious. Alternatively, a medication given with the wrong dose (chemotherapy given with too low of a dose) can have an AdverseEvent.resultingCondition.severity = mild, yet a AdverseEvent.seriousness = serious. Another example would be a beta blocker clinical trial where patients with asthma should be excluded, yet a patient with asthma was included and had an asthmatic episode where AdverseEvent.resultingCondition.severity = mild, yet a AdverseEvent.seriousness = serious. |
AdverseEvent.outcome | |
Element Id | AdverseEvent.outcome |
Definition | Describes the type of outcome from the adverse event, such as resolved, recovering, ongoing, resolved-with-sequelae, or fatal. |
Cardinality | 0..1 |
Terminology Binding | AdverseEvent Outcome (Preferred) |
Type | CodeableConcept |
Summary | true |
AdverseEvent.recorder | |
Element Id | AdverseEvent.recorder |
Definition | Information on who recorded the adverse event. May be the patient or a practitioner. |
Cardinality | 0..1 |
Type | Reference(Patient | Practitioner | PractitionerRole | RelatedPerson) |
Patterns | Reference(Patient,Practitioner,PractitionerRole,RelatedPerson): Common patterns = Participant |
Summary | true |
AdverseEvent.participant | |
Element Id | AdverseEvent.participant |
Definition | Indicates who or what participated in the adverse event and how they were involved. |
Cardinality | 0..* |
Summary | true |
AdverseEvent.participant.function | |
Element Id | AdverseEvent.participant.function |
Definition | Distinguishes the type of involvement of the actor in the adverse event, such as contributor or informant. |
Cardinality | 0..1 |
Terminology Binding | AdverseEvent Participant Function (Example) |
Type | CodeableConcept |
Summary | true |
AdverseEvent.participant.actor | |
Element Id | AdverseEvent.participant.actor |
Definition | Indicates who or what participated in the event. |
Cardinality | 1..1 |
Type | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | Device | RelatedPerson) |
Patterns | Reference(Practitioner,PractitionerRole,Organization,CareTeam,Patient,Device,RelatedPerson): Common patterns = Participant |
Summary | true |
Comments | For example, the physician prescribing a drug, a nurse administering the drug, a device that administered the drug, a witness to the event, or an informant of clinical history. |
AdverseEvent.suspectEntity | |
Element Id | AdverseEvent.suspectEntity |
Definition | Describes the entity that is suspected to have caused the adverse event. |
Cardinality | 0..* |
Summary | true |
AdverseEvent.suspectEntity.instance[x] | |
Element Id | AdverseEvent.suspectEntity.instance[x] |
Definition | Identifies the actual instance of what caused the adverse event. May be a substance, medication, medication administration, medication statement or a device. |
Cardinality | 1..1 |
Type | CodeableConcept|Reference(Immunization | Procedure | Substance | Medication | MedicationAdministration | MedicationUsage | Device) |
Patterns | Reference(Immunization,Procedure,Substance,Medication,MedicationAdministration,MedicationUsage,Device): No common pattern |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Alternate Names | Substance or Medication or Device |
Summary | true |
AdverseEvent.suspectEntity.causality | |
Element Id | AdverseEvent.suspectEntity.causality |
Definition | Information on the possible cause of the event. |
Cardinality | 0..1 |
Summary | true |
AdverseEvent.suspectEntity.causality.assessmentMethod | |
Element Id | AdverseEvent.suspectEntity.causality.assessmentMethod |
Definition | The method of evaluating the relatedness of the suspected entity to the event. |
Cardinality | 0..1 |
Terminology Binding | AdverseEventCausalityMethod (Example) |
Type | CodeableConcept |
Summary | true |
AdverseEvent.suspectEntity.causality.entityRelatedness | |
Element Id | AdverseEvent.suspectEntity.causality.entityRelatedness |
Definition | The result of the assessment regarding the relatedness of the suspected entity to the event. |
Cardinality | 0..1 |
Terminology Binding | AdverseEventCausalityAssessment (Example) |
Type | CodeableConcept |
Summary | true |
AdverseEvent.suspectEntity.causality.author | |
Element Id | AdverseEvent.suspectEntity.causality.author |
Definition | The author of the information on the possible cause of the event. |
Cardinality | 0..1 |
Type | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
Patterns | Reference(Practitioner,PractitionerRole,Patient,RelatedPerson): Common patterns = Participant |
Summary | true |
AdverseEvent.contributingFactor | |
Element Id | AdverseEvent.contributingFactor |
Definition | The contributing factors suspected to have increased the probability or severity of the adverse event. |
Cardinality | 0..* |
Summary | true |
AdverseEvent.contributingFactor.item[x] | |
Element Id | AdverseEvent.contributingFactor.item[x] |
Definition | The item that is suspected to have increased the probability or severity of the adverse event. |
Cardinality | 1..1 |
Terminology Binding | AdverseEvent Contributing Factor (Example) |
Type | Reference(Condition | Observation | AllergyIntolerance | FamilyMemberHistory | Immunization | Procedure | DocumentReference)|CodeableConcept |
Patterns | Reference(Condition,Observation,AllergyIntolerance,FamilyMemberHistory,Immunization,Procedure,DocumentReference): No common pattern |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Summary | true |
AdverseEvent.preventiveAction | |
Element Id | AdverseEvent.preventiveAction |
Definition | Preventive actions that contributed to avoiding the adverse event. |
Cardinality | 0..* |
Summary | true |
AdverseEvent.preventiveAction.item[x] | |
Element Id | AdverseEvent.preventiveAction.item[x] |
Definition | The action that contributed to avoiding the adverse event. |
Cardinality | 1..1 |
Terminology Binding | AdverseEvent Preventive Action (Example) |
Type | Reference(Immunization | Procedure | DocumentReference | MedicationAdministration | MedicationRequest)|CodeableConcept |
Patterns | Reference(Immunization,Procedure,DocumentReference,MedicationAdministration,MedicationRequest): No common pattern |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Summary | true |
AdverseEvent.mitigatingAction | |
Element Id | AdverseEvent.mitigatingAction |
Definition | The ameliorating action taken after the adverse event occured in order to reduce the extent of harm. |
Cardinality | 0..* |
Summary | true |
AdverseEvent.mitigatingAction.item[x] | |
Element Id | AdverseEvent.mitigatingAction.item[x] |
Definition | The ameliorating action taken after the adverse event occured in order to reduce the extent of harm. |
Cardinality | 1..1 |
Terminology Binding | AdverseEvent Mitigating Action (Example) |
Type | Reference(Procedure | DocumentReference | MedicationAdministration | MedicationRequest)|CodeableConcept |
Patterns | Reference(Procedure,DocumentReference,MedicationAdministration,MedicationRequest): No common pattern |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Summary | true |
AdverseEvent.supportingInfo | |
Element Id | AdverseEvent.supportingInfo |
Definition | Supporting information relevant to the event. |
Cardinality | 0..* |
Summary | true |
AdverseEvent.supportingInfo.item[x] | |
Element Id | AdverseEvent.supportingInfo.item[x] |
Definition | Relevant past history for the subject. In a clinical care context, an example being a patient had an adverse event following a pencillin administration and the patient had a previously documented penicillin allergy. In a clinical trials context, an example is a bunion or rash that was present prior to the study. Additionally, the supporting item can be a document that is relevant to this instance of the adverse event that is not part of the subject's medical history. For example, a clinical note, staff list, or material safety data sheet (MSDS). Supporting information is not a contributing factor, preventive action, or mitigating action. |
Cardinality | 1..1 |
Terminology Binding | AdverseEvent Supporting Information (Example) |
Type | Reference(Condition | Observation | AllergyIntolerance | FamilyMemberHistory | Immunization | Procedure | DocumentReference)|CodeableConcept |
Patterns | Reference(Condition,Observation,AllergyIntolerance,FamilyMemberHistory,Immunization,Procedure,DocumentReference): No common pattern |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Summary | true |
AdverseEvent.study | |
Element Id | AdverseEvent.study |
Definition | The research study that the subject is enrolled in. |
Cardinality | 0..* |
Type | Reference(ResearchStudy) |
Summary | true |