9. Medical Records/Information Management (Document Management)


Contents



9 . Medical Records/Information Management (Document Management)

Chapter Chair/Editor:

Wayne R. Tracy, MS Health Patterns, LLC

Chapter Chair/Editor:

Michelle L. Dougherty, RHIA American Health Information Management Association

9.1 CHAPTER 9 CONTENTS

9.2 PURPOSES

This chapter currently supports document management. In the future, it is intended also to support the data exchange needs of applications supporting other medical record functions, including chart location and tracking, deficiency analysis, consents, and release of information. The main purpose of the medical record is to produce an accurate, legal, and legible document that serves as a comprehensive account of healthcare services provided to a patient.

Document/reports supported in this chapter will meet the criteria as described in Chapter 7 (section 7.2 _ Purpose). The appropriate use of MDM messages versus ORU message has been clarified in 7.2.

9.2.1 Definition of Terms and Concepts

This section provides definition of terms used throughout this chapter. The intent of this part is to provide clarification on use and interpretation.

9.2.1.1 Addendum:

An appendage to an existing document that contains supplemental information. The parent document remains in place and its content is unaltered.

9.2.1.2 Archived:

A storage status in which a document has been stored off-line for long-term access.

9.2.1.3 Canceled:

An availability status in which a document has been _removed_ from a patient_s record with no replacement. This is done when a document has been erroneously created or assigned to the incorrect patient.

9.2.1.4 Composite document:

A document which consists of an original document and one or more addenda.

9.2.1.5 Document completion table:

The following terms are used to describe the workflow progression of a document:

9.2.1.6 Authenticated:

A completion status in which a document or entry has been signed manually or electronically by one or more individuals who attest to its accuracy. No explicit determination is made that the assigned individual has performed the authentication. While the standard allows multiple instances of authentication, it would be typical to have a single instance of authentication, usually by the assigned individual.

9.2.1.6.1 Dictated:

A completion status in which information has been orally recorded but not yet transcribed.

9.2.1.6.2 Documented:

A completion status in which document content, other than dictation, has been received but has not been translated into the final electronic format. Examples include paper documents, whether hand-written or typewritten, and intermediate electronic forms, such as voice to text.

9.2.1.6.3 In Progress/Assigned:

A workflow status in which the recipient has assigned the material to personnel to perform the task of transcription. The document remains in this state until the document is transcribed.

9.2.1.6.4 Incomplete:

A completion status in which information is known to be missing from a document.

9.2.1.7 Legally Authenticated:

A completion status in which a document or entry has been signed manually or electronically by the individual who is legally responsible for that document or entry. This is the most mature state in the workflow progression.

9.2.1.7.1 Pre-Authenticated:

A completion status in which a document is transcribed but not authenticated.

9.2.1.8 Edited Document:

A document that alters an existing document which had not been made available for patient care (see also Section 9.1.1.10, _Replacement document_).

9.2.1.9 New or Original Document:

The first version of a document. The original may or may not be final or authenticated. An original document should have a set of associated statuses to define its current condition.

9.2.1.10 Obsolete:

An availability status in which a document has been replaced by a document which contains revised content.

9.2.1.11 Purged:

A storage status in which a document is no longer available in this system.

9.2.1.12 Replacement Document:

A document that replaces an existing document. The original document becomes obsolete, but is still retained in the system for historical reference.

9.2.1.13 Restricted:

A confidentiality status in which access to a document has institutionally assigned limitations.

9.2.1.14 Revised document:

This is not a supported trigger event. See Sections 9.1.1.6, _Edited document_, and 9.1.1.10 _Replacement document_.

9.2.1.15 Transcription:

A process of transforming dictated or otherwise documented information into an electronic format.

9.3 DOCUMENT MANAGEMENT SECTION

This section defines the Medical Document Management (MDM) transaction set. It supports transmission of new or updated documents or information about their status(es). The trigger events and messages may be divided into two broad categories. One which describes the status of a document only and the other that describes the status and contains the document content itself.

The document management section is concerned primarily with the management of those documents and entries which are created as a result of a transcription process. Documents may be represented as a CDA document. See ANSI/HL7 CDA R1.0-2000 Section 2.5.2 for the correct method of transmitting CDA documents within an MDM message. These documents are created in two distinct contexts, one of which is related to an order and describes the procedures or activities associated with that order, and another which occurs independent of the order process. In this version we have added the ORC, OBR and associated NTE segments in order to provide full ordering context when appropriate for document management messages. The scope of this section also includes any document that contains data derived from orders or results but which must be treated as aggregate display data due to system limitations. This is a transition strategy to support integration of data across the continuum of care.

The content of a document can be represented with one or more observation segments (OBX). Where headings or separations naturally exist within the text, it is preferred that each of these blocks be represented as a separate OBX record. Where systems are able to decompose the text into separate medical concepts, the most atomic level of granularity of content should be represented, ideally with each medical concept being represented in its own OBX segment. Many of these concepts can be represented as coded entities.

9.4 ASSUMPTIONS

Within this section, we have created a single message whose contents vary predicated on the trigger event. The following assumptions are made when the Medical Document Management (MDM) message is used:

9.5 TRIGGER EVENTS AND MESSAGE DEFINITIONS

Each triggering event is listed below, along with the applicable form of the message exchange. The notation used to describe the sequence, optionality, and repetition of segments is described in Chapter 2, _Format for Defining Abstract Messages._ There are two classes of events, those which contain notifications only, and those which contain both notifications and content (text contained in OBX segments). Note that the event is encapsulated in MSH-9 and the event segment is deprecated for all MDM message cases as of version 2.5. When -MSH-9 is valued, the value of EVN-1 must be the same.

These triggering events are mainly associated with documents or entries that will be or have been transcribed. The types and appearance of the transcribed documents can vary greatly within a healthcare organization and between organizations. However, the main purpose of the transcription process is to document patient care or diagnostic results in a legible manner; these documents then become part of the legal medical record. The conceptual purpose of document notification is to facilitate updating the receiving system(s) with information from the source system(s), typically dictation or transcription systems, to indicate that an electronic document has been created or altered. The document notification message can be attached to an entire document (i.e. transcribed document) or can be transmitted stand-alone. In either case, the document notification is transmitted in the form of an unsolicited update or in response to a record-oriented query. A document notification message can be created under a variety of circumstances such as when: 1) dictation has been completed; 2) a document has been transcribed; or 3) the status of a document has been changed, i.e. when a document has been authenticated.

Also, the orders represented by the ORC/OBR segments must be wholly and exclusively satisfied by the TXA/OBX content. _Wholly satisfied_ means there are no other orders related to the TXA/OBX content other than those specified by the ORC/OBR segments. _Exclusively satisfied_ means that the actions described by the ORC/OBR segments do not contain actions not addressed by the TXA/OBX content. Thus, the TXA/OBX context must satisfy all instances of ORC/OBR as indicated by ORC-7 Quantity/Timing, OBR-27 Quantity/Timing or the TQ1/ TQ2 segments.

9.5.1 MDM/ACK - Original Document Notification (Event T01)

This is a notification of the creation of a document without the accompanying content. There are multiple approaches by which systems become aware of documents:

Scenario A: A document is dictated and chart tracking system is notified that it has been dictated and is awaiting transcription.

Scenario B: Dictation is transcribed and chart tracking system is notified that the document exists and requires authentication.

Scenario C: A provider orders a series of three X-rays. The radiologist dictates a single document which covers all three orders. Multiple placer numbers are used to identify each of these orders.


MDM^T01^MDM_T01 Original Document Notification Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the observation request (OBR)

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB

ACK^T01^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.2 MDM/ACK - Original Document Notification and Content (Event T02)

This is a notification of the creation of a document with the accompanying content.

Scenario A: Dictation is transcribed and the chart tracking system is notified that the document exists and requires authentication. The content of the document is transmitted along with the notification.

Scenario B: A provider orders a series of three X-rays. The radiologist_s dictation is transcribed in a single document, which covers all three orders. Multiple placer numbers are used to identify each of the orders within the single document message. The notification and document content are transmitted.

MDM^T02^MDM_T02 Original Document Notification & Content Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the observation (OBR)

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB
{ OBX Observation/Result (one or more required)

DB
[ { NTE } ] Notes and comments about the observation (OBX)

DB
}



ACK^T02^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.3 MDM/ACK - Document Status Change Notification (Event T03)

This is a notification of a change in a status of a document without the accompanying content.

Scenario: A document is authenticated. Notification is sent to the chart tracking system and is used to update the document status from pre-authenticated to authenticated or legally authenticated.

A change in any of the following independent status characteristics would cause a message to be sent:

MDM^T03^MDM_T01 Document Status Change Notification Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segmentn

DB
EVN Event Type (

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB

ACK^T03^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.4 MDM/ACK - Document Status Change Notification and Content (Event T04

This is a notification of a change in a status of a document with the accompanying content.

Scenario: A document is authenticated. Notification is sent to the chart tracking system and is used to update the document status from pre-authenticated to authenticated or legally authenticated. The document content is also transmitted.

MDM^T04^MDM_T02 Document Status Change Notification & Content Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB
{OBX Observation/Result (one or more required)

DB
[ { NTE } ] Notes and comments segment for OBX

DB
}



ACK^T04^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.5 MDM/ACK - Document Addendum Notification (Event T05)

This is a notification of an addendum to a document without the accompanying content.

Scenario: Author dictates additional information as an addendum to a previously transcribed document. A new document is transcribed. This addendum has its own new unique document ID that is linked to the original document via the parent ID. Addendum document notification is transmitted. This creates a composite document.

MDM^T05^MDM_T01 Document Addendum Notification Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB

ACK^T05^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.6 MDM/ACK - Document Addendum Notification and Content (Event T06)

This is a notification of an addendum to a document with the accompanying content.

Scenario: Author dictates additional information as an addendum to a previously transcribed document. A new document is transcribed. This addendum has its own new unique document ID that is linked to the original document via the parent ID. Addendum document notification is transmitted, along with the document content. This creates a composite document.

MDM^T06^MDM_T02 Document Addendum Notification & Content Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB
{OBX Observation/Result (one or more required)

DB
[ { NTE } ] Notes and comments about the OBX

DB
}



ACK^T06^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.7 MDM/ACK - Document Edit Notification (Event T07)

Note: The only valid use of this trigger event is for documents whose availability status is _Unavailable,_ i.e. the document has not been made available for patient care.

This is a notification of an edit to a document without the accompanying content.

Scenario: Errors, which need to be corrected, are discovered in a document. The original document is edited, and an edit notification is sent.

MDM^T07^MDM_T01 Document Edit Notification Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB

ACK^T07^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.8 MDM/ACK - Document Edit Notification and Content (Event T08)

Note: The only valid use of this trigger event is for documents whose availability status is "Unavailable," i.e. the document has not been made available for patient care.

This is a notification of an edit to a document with the accompanying content.

Scenario: Errors, which need to be corrected, are discovered in a document. The original document is edited, and an edit notification and document content are sent.

MDM^T08^MDM_T02 Document Edit Notification & Content Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB
{OBX Observation/Result (one or more required)

DB
[ { NTE } ] Notes and comments about the OBX

DB
}



ACK^T08^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.9 MDM/ACK - Document Replacement Notification (Event T09)

Note: This trigger event is generally used when the original document availability status is _Available._

This is a notification of replacement to a document without the accompanying content.

Scenario: Errors discovered in a document are corrected. The original document is replaced with the revised document. The replacement document has its own new unique document ID that is linked to the original document via the parent ID. The availability status of the original document is changed to _Obsolete_ but the original document should be retained in the system for historical reference. Document replacement notification is sent.

MDM^T09^MDM_T01 Document Replacement Notification Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB

ACK^T09^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.10 MDM/ACK - Document Replacement Notification and Content (Event T10)

Scenario: Errors discovered in a document are corrected. The original document is replaced with the revised document. The replacement document has its own new unique document ID that is linked to the original document via the parent ID. The availability status of the original document is changed to _Obsolete_ but the original document should be retained in the system for historical reference. Document replacement notification and document content are sent.

MDM^T10^MDM_T02 Document Replacement Notification & Content Status Chapter DB Ref.
MSH Message Header

DB
[ { STF } ] Software Segment

DB
EVN Event Type B, v2.5
DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin


TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB
{OBX Observation/Result (one or more required)

DB
[ { NTE } ] Notes and comments about the OBX

DB
}



ACK^T10^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software Segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.5.11 MDM/ACK - Document Cancel Notification (Event T11)

This is a notification of a cancellation of a document. This trigger event should be used only for an original document with an availability status of _Unavailable._ When a document has been made available for patient care, the process should be to replace the original document, which then becomes obsolete. The replacement document describes why the erroneous information exists.

Scenario: When the author dictated a document, the wrong patient identification was given, and the document was transcribed and sent to the wrong patient_s record. When the error is discovered, a cancellation notice is sent to remove the document from general access in the wrong patient_s record. In these cases, a reason should be supplied in the cancellation message. To protect patient privacy, the correct patient_s identifying information should not be placed on the erroneous document that is retained in the wrong patient_s record for historical reference. A new document notification and content will be created using a T02 (original document notification and content) event and sent for association with the correct patient_s record.

MDM^T11^MDM_T01 Document Cancel Notification Status Chapter DB Ref.
MSH Message Header

DB
[ { STF } ] Software Segment

DB
EVN Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
[{ --- COMMON_ORDER begin


ORC Common order segment

DB
[{ --- TIMING begin

TQ1 Timing/Quantity

DB
[ { TQ2 } ] Timing/Quantity Order Sequence

DB
}] --- TIMING end


OBR Observation request segment

DB
[ { NTE } ] Notes and comments about the OBR

DB
}] --- COMMON_ORDER end


TXA Document Notification

DB

ACK^T11^ACK General Acknowledgment Status Chapter DB Ref.
MSH Message Header

DB
[ { SFT } ] Software segment

DB
MSA Message Acknowledgment

DB
[ { ERR } ] Error Information

DB

9.6 MESSAGE SEGMENTS

9.6.1 TXA - Transcription Document Header Segment

The TXA segment contains information specific to a transcribed document but does not include the text of the document. The message is created as a result of a document status change. This information updates other healthcare systems and allows them to identify reports that are available in the transcription system. By maintaining the TXA message information in these systems, the information is available when constructing queries to the transcription system requesting the full document text.

HL7 Attribute Table _ TXA _ Transcription Document Header

SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME DB Ref.
1 4 SI R

00914 Set ID- TXA DB
2 30 IS R
0270 00915 Document Type DB
3 2 ID C
0191 00916 Document Content Presentation DB
4 26 TS O

00917 Activity Date/Time DB
5 250 XCN C Y
00918 Primary Activity Provider Code/Name DB
6 26 TS O

00919 Origination Date/Time DB
7 26 TS C

00920 Transcription Date/Time DB
8 26 TS O Y
00921 Edit Date/Time DB
9 250 XCN O Y
00922 Originator Code/Name DB
10 250 XCN O Y
00923 Assigned Document Authenticator DB
11 250 XCN C Y
00924 Transcriptionist Code/Name DB
12 30 EI R

00925 Unique Document Number DB
13 30 EI C

00926 Parent Document Number DB
14 22 EI O Y
00216 Placer Order Number DB
15 22 EI O

00217 Filler Order Number DB
16 30 ST O

00927 Unique Document File Name DB
17 2 ID R
0271 00928 Document Completion Status DB
18 2 ID O
0272 00929 Document Confidentiality Status DB
19 2 ID O
0273 00930 Document Availability Status DB
20 2 ID O
0275 00932 Document Storage Status DB
21 30 ST C

00933 Document Change Reason DB
22 250 PPN C Y
00934 Authentication Person, Time Stamp DB
23 250 XCN O Y
00935 Distributed Copies (Code and Name of Recipients) DB

9.6.1.0 TXA Field Definitions

9.6.1.1 TXA-1 Set ID - TXA (SI) 00914

Definition: This field contains a number that uniquely identifies this transaction for the purpose of adding, changing, or deleting the transaction.

9.6.1.2 TXA-2 Document Type (IS) 00915

Definition: This field identifies the type of document (as defined in the transcription system). Refer to User-Defined Table 0270 - Document Type for suggested values. The organization is free to add more entries.

User-Defined Table 0270 - Document Type

Value Description Comment
AR Autopsy report
CD Cardiodiagnostics
CN Consultation
DI Diagnostic imaging
DS Discharge summary
ED Emergency department report
HP History and physical examination
OP Operative report
PC Psychiatric consultation
PH Psychiatric history and physical examination
PN Procedure note
PR Progress note
SP Surgical pathology
TS Transfer summary

9.6.1.3 TXA-3 Document Content Presentation (ID) 00916

Definition: This is a conditional field which is required whenever the message contains content as presented in one or more OBX segments. This field identifies the method by which this document was obtained or originated. Refer to HL7 Table 0191 _ Type Of Referenced Data for valid values.

HL7 Table 0191 - Type Of Referenced Data

Value Description Comment
AP Other application data, typically uninterpreted binary data (HL7 V2.3 and later)
AU Audio data (HL7 V2.3 and later)
FT Formatted text (HL7 V2.2 only)
IM Image data (HL7 V2.3 and later)
multipart MIME multipart package (CDA per 2.5.2)
NS Non-scanned image (HL7 V2.2 only)
SD Scanned document (HL7 V2.2 only)
SI Scanned image (HL7 V2.2 only)
TEXT Machine readable text document (HL7 V2.3.1 and later)
TX Machine readable text document (HL7 V2.2 only)

9.6.1.4 TXA-4 Activity Date/Time (TS) 00917

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date/time identified in the document as the date a procedure or activity was performed. This date can identify date of surgery, non-invasive procedure, consultation, examination, etc.

9.6.1.5 TXA-5 Primary Activity Provider Code/Name (XCN) 00918

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ < Assigning Jurisdiction (CWE)> ^ < Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: This field contains the name of the person identified in the document as being responsible for performing the procedure or activity. This field includes the code and name (if available) of the caregiver. This field is conditional based upon the presence of a value in TXA-4-Activity Date/Time.

9.6.1.6 TXA-6 Origination Date/Time (TS) 00919

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date and time the document was created (i.e. dictated, recorded, etc.).

9.6.1.7 TXA-7 Transcription Date/Time (TS) 00920

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date and time the input was actually transcribed. This field is conditional based upon the presence of a value in TXA-17-Document completion status of anything except _dictated._

9.6.1.8 TXA-8 Edit Date/Time (TS) 00921

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: This field contains the date and time the document was edited.

9.6.1.9 TXA-9 Originator Code/Name (XCN) 00922

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ < Assigning Jurisdiction (CWE)> ^ < Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: This field identifies the person who originated (i.e. dictated) the document. The document originator may differ from the person responsible for authenticating the document.

9.6.1.10 TXA-10 Assigned Document Authenticator (XCN) 00923

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ < Assigning Jurisdiction (CWE)> ^ < Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: This field identifies the person(s) responsible for authenticating the document, who may differ from the originator. Multiple persons may be responsible for authentication, especially in teaching facilities. This field is allowed to repeat an undefined number of times.

9.6.1.11 TXA-11 Transcriptionist Code/Name (XCN) 00924

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ < Assigning Jurisdiction (CWE)> ^ < Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: This field identifies the person transcribing the document. This is a conditional value; it is required on all transcribed documents.

9.6.1.12 TXA-12 Unique Document Number (EI) 00925

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (st)> ^ <universal ID type (ID)>

Definition: This field contains a unique document identification number assigned by the sending system. This document number is used to assist the receiving system in matching future updates to the document, as well as to identify the document in a query. When the vendor does not provide a unique document ID number, some type of document identifier should be entered here, or the Unique Document File name should be utilized. See Chapter 2, Section 2.9.55, _XTN - extended telecommunication number._ Where the system does not customarily have a document filler number, this number could serve as that value, as well.

9.6.1.13 TXA-13 Parent Document Number (EI) 00926

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)>

Definition: This field contains a document number that identifies the parent document to which this document belongs. The parent document number can be used to assist the receiving system in matching future updates to this document. This is a conditional field that is always required on T05 (document addendum notification), T06 (document addendum notification and content), T09 (document replacement notification), and T10 (document replacement notification and content) events.

9.6.1.14 TXA-14 Placer Order Number (EI) 00216

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)>

Definition: This field is the placer application_s order number.

This is a composite field. The first component is a string of characters that identifies an individual order (. i.e. OBR). It is assigned by the placer (ordering application). It identifies an order uniquely among all orders from a particular ordering application. The second through fourth components contain the (filler) assigning authority of the placing application. The (filler) assigning authority is a string of characters that will be uniquely associated with an application. A given institution or group of intercommunicating institutions should establish a unique list of applications that may be potential placers and fillers and assign unique entity identifiers. The components are separated by component delimiters.

9.6.1.15 TXA-15 Filler Order Number (EI) 00217

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

Components: <entity identifier (ST)> ^ <namespace ID (IS)> ^ <universal ID (ST)> ^ <universal ID type (ID)>

Definition: This field is the order number associated with the filling application. Where a transcription service or similar organization creates the document and uses an internally unique identifier, that number should be inserted in this field. Its first component is a string of characters that identifies an order detail segment (i.e. OBR). This string must uniquely identify the order (as specified in the order detail segment) from other orders in a particular filling application (, i.e. transcription service). This uniqueness must persist over time. Where a number is reused over time, a date can be affixed to the non-unique number to make it unique.

The second through fourth components contains the (filler) assigning authority. The (filler) assigning authority is a string of characters that uniquely defines the application from other applications on the network. The second through fourth components of the filler order number always identify the actual filler of an order.

For further details, please see the definitions provided in Chapter 4.

9.6.1.16 TXA-16 Unique Document File Name (ST) 00927

Definition: This field contains a unique name assigned to a document by the sending system. The file name is used to assist the receiving system in matching future updates to the document.

9.6.1.17 TXA-17 Document Completion Status (ID) 00928

Definition: This field identifies the current completion state of the document. This is a required, table-driven field. Refer to HL7 Table 0271 - Document Completion Status for valid values.

HL7 Table 0271 - Document completion status

Value Description Comment
DI Dictated
DO Documented
IP In Progress
IN Incomplete
PA Pre-authenticated
AU Authenticated
LA Legally authenticated

Figure 9-1. Document completion status state transition table

Transition (Action) Old State New State
T01 Original Notification

T02 Original Notification and Content

NA Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated

T03 Status Change Notification

T04 Status Change Notification and Content

Dictated
In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated


In Progress
Incomplete

Pre-authenticated

Authenticated

Legally authenticated


Incomplete Pre-authenticated

Authenticated

Legally authenticated


Pre-authenticated Authenticated

Legally authenticated


Authenticated Legally authenticated

Legally authenticated NA

Documented Pre-authenticated

Authenticated

Legally authenticated

T05 Addendum Notification

T06 Addendum Notification and Content

NA Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated

T07 Edit Notification

T08 Edit Notification and Content

Dictated
In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated


In Progress
Incomplete

Pre-authenticated

Authenticated

Legally authenticated


Incomplete Pre-authenticated

Authenticated

Legally authenticated


Pre-authenticated Authenticated

Legally authenticated


Authenticated Legally authenticated

Legally authenticated NA

Documented Pre-authenticated

Authenticated

Legally authenticated

T09 Replacement Notification

T10 Replacement Notification and Content

NA Dictated

In Progress

Incomplete

Pre-authenticated

Authenticated

Legally authenticated

T11 Cancel Notification Dictated In Progress Incomplete Pre-authenticated and Availability status of _Unavailable_ Canceled

9.6.1.18 TXA-18 Document Confidentiality Status (ID) 00929

Definition: This is an optional field which identifies the degree to which special confidentiality protection should be applied to this information. The assignment of data elements to these categories is left to the discretion of the healthcare organization. Refer to HL7 Table 0272 - Document Confidentiality Status for valid values.

HL7 Table 0272 - Document Confidentiality Status

Value Description Comment
V Very restricted
R Restricted
U Usual control

9.6.1.19 TXA-19 Document Availability Status (ID) 00930

Definition: This is an optional field which identifies a document_s availability for use in patient care. If an organization_s business rules allow a document to be used for patient care before it is authenticated, the value of this field should be set to _AV._ If a document has been made available for patient care, it cannot be changed or deleted. If an erroneous document has been made available at any point in time and a replacement is not appropriate, then it may be marked as _Canceled_ and removed, as in the case of a document being assigned to the wrong patient. Additional information must be provided via an addendum, which is separately authenticated and date/time stamped. If the content of a document whose status is _Available_ must be revised, this is done by issuing a replacement, which is separately authenticated and date/time stamped. Refer to HL7 Table 0273 - Document Availability Status for valid values.

HL7 Table 0273 - Document Availability Status

Value Description Comment
AV Available for patient care
CA Deleted
OB Obsolete
UN Unavailable for patient care

Figure 9-2. Document availability status state transition table

Transition (Action) Old State New State Notes
T01 Original Notification

T02 Original Notification and Content

NA Unavailable

Available


T03 Status Change Notification

T04 Status Change Notification and Content

Unavailable
Unavailable

Available

Obsolete



Available
Available

Obsolete



Obsolete NA
T05 Addendum Notification

T06 Addendum Notification and Content

NA Unavailable

Available


T07 Edit Notification

T08 Edit Notification and Content

Unavailable
Unavailable

Available


T09 Replacement Notification

T10 Replacement Notification and Content

NA Unavailable

Available

Set parent document to "obsolete"
T11 Cancel Unavailable Delete

Note: NA means not applicable.

9.6.1.20 TXA-20 Document Storage Status (ID) 00932

Definition: This optional field identifies the storage status of the document. Refer to HL7 Table 0275 - Document Storage Status for valid values.

HL7 Table 0275 - Document Storage Status

Value Description Comment
AC Active
AA Active and archived
AR Archived (not active)
PU Purged

9.6.1.21 TXA-21 Document Change Reason (ST) 00933

Definition: This free text field (limited to 30 characters) contains the reason for document status change.

9.6.1.22 TXA-22 Authentication Person, Time Stamp (set) (PPN) 00934

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Date/Time Action Performed (TS)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Date/Time Action Performed (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Date/Time Action Performed (TS)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Date/Time Action Performed (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: This field contains a set of components describing by whom and when authentication was performed (either manually or electronically). The Date/Time Action Performed component describes the date/time of the authentication (Authentication Time Stamp). The remaining components identify the person performing the authentication (Authentication Person). If either of the Authenticating Person or the Authentication Time Stamp is valued as non-null, then both must be valued as non-null.

This is a conditional field. When the status of TXA-17-Document completion status is equal to AU (authenticated) or LA (legally authenticated), all components are required.

9.6.1.23 TXA-23 Distributed Copies (XCN) 00935

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ <Assigning Jurisdiction (CWE)> ^ <Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <ID Number (ST)> ^ <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <Degree (e.g., MD) (IS)> ^ <Source Table (IS)> ^ <Assigning Authority (HD)> ^ <Name Type Code (ID)> ^ <Identifier Check Digit (ST)> ^ <Check Digit Scheme (ID)> ^ <Identifier Type Code (ID)> ^ <Assigning Facility (HD)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)> ^ < Assigning Jurisdiction (CWE)> ^ < Assigning Agency or Department (CWE)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Assigning Authority (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Assigning Facility (HD): <Namespace ID (IS)> & <Universal ID (ST)> & <Universal ID Type (ID)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Assigning Jurisdiction (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Subcomponents for Assigning Agency or Department (CWE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)> & <Coding System Version ID (ST)> & <Alternate Coding System Version ID (ST)> & <Original Text (ST)>

Definition: This field identifies the persons who received a copy of this document.

9.6.2 OBX - Observation Segment Usage

The OBX segment is documented in its entirety in Chapter 7. Its usage as it applies to Medical Records/ Information Management is documented here for clarity.

HL7 Attribute Table - OBX _ Observation Segment

SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME DB Ref.
1 4 SI R

00569 Set ID- OBX DB
2 2 ID R
0125 00570 Value Type DB
3 250 CE O

00571 Observation Identifier DB
4 20 ST O

00572 Observation Sub-Id DB
5 * * C/R

00573 Observation Value DB
6 250 CE O

00574 Units DB
7 60 ST O

00575 References Range DB
8 5 ID O Y/5 0078 00576 Abnormal Flags DB
9 5 NM O

00577 Probability DB
10 2 ID O
0080 00578 Nature of Abnormal Test DB
11 1 ID R/NA
0085 00579 Observation Result Status DB
12 26 TS C

00580 Date Last Observation Normal Values DB
13 20 ST C

00581 User Defined Access Checks DB
14 26 TS O

00582 Date/Time of Observation DB
15 250 CE C

00583 Producer_s ID DB
16 250 XCN O Y
00584 Responsible Observer DB
17 250 CE O Y
00936 Observation Method DB
18 22 EI O Y
01479 Equipment Instance Identifier DB
19 26 TS O

01480 Date/Time of the Analysis DB

C = For fields OBX-12, OBX-13, and OBX-15, the field should be valued conditionally. These fields should be valued only when the result (OBX-5-observation value) contains a single concept. This is typically true when the result type is numeric, ID, or CE. When multiple medical concepts are expressed, the values of these three fields are ambiguous.* = 256 K or site negotiated

Specialized usage: Observation Identifier/Observation Sub-ID have been used as optional fields that are not required in unstructured text where the nature of the document has been identified in TXA-2-Document type, which is a required field, but is expressly allowed in the richer structured documentation. An example includes cases where anatomic reports may have separate OBXs for gross examination, microscopic examination, clinical impression, and final diagnosis. Another possible use includes imbedding non-textual observations within textual reports.

9.7 EXAMPLE MESSAGE

The following is an example of an original transmission of a history and physical examination which has been authenticated prior to this message being initiated:

MSH|...<cr>

EVN|T02|19960215154405||04|097220^Smith^Frederick^A^Jr^Dr^MD^| <cr>

PID|...<cr>

PR1|...<cr>

TXA|0001|HP^history & physical|TX^text|19960213213000|099919^Tracy^Wayne^R^III^Mr^MS^| 19960213153000|19960215134500||099919^Tracy^Wayne^R^III^Mr^MS^|097220^Smith^Frederick^A^Jr^Dr^MD^|01234567^Baxter^Catherine^S^Ms|1996021500001^transA|||example.doc|LA|UC|AV||AC|||||097220^Smith^Frederick^A^Jr^Dr^MD^| <cr>

OBX|1|CE|2000.40^CHIEF COMPLAINT|| ... <cr>

OBX|2|ST|2000.01^SOURCE||PATIENT <cr>

OBX|3|TX|2000.02^PRESENT ILLNESS||SUDDEN ONSET OF CHEST PAIN. 2 DAYS, PTA ASSOCIATED WITH NAUSEA, VOMITING & SOB. NO RELIEF WITH ANTACIDS OR NTG. NO OTHER SX. NOT PREVIOUSLY ILL.<cr>

.

.

and so on.

9.8 QUERY

A query may be used to retrieve a list of documents or a specific document. See Chapter 5 for details of queries.

9.8.1 QRY/DOC - Document Query (Event T12)

QRY^T12^QRY Document Query Group Name Status Chapter DB Ref.
MSH Message Header

2 DB






QRD Query Definition

2 DB
[ QRF ] Query Filter

2 DB

DOC^T12^DOC_T12 Document Response Group Name Status Chapter DB Ref.
MSH Message Header

DB
MSA Message Acknowledgement

DB
[ ERR ] Error

DB
[ QAK ] Query Acknowledgement

DB
QRD Query Definition

DB
{




[ EVN ] Event Type

DB
PID Patient Identification

DB
PV1 Patient Visit

DB
TXA Document Notification

DB
[ { OBX } ] Observation

DB
}




[ DSC ] Continuation Pointer

DB

9.8.1.1 Query usage notes

The QRD and QRF segments are defined in Chapter 5, Sections 5.10.5.3, _QRD - original style query definition segment,_ and 5.10.5.4, _QRF - original style query filter segment._

The subject filters contained in the QRD and QRF segments describe the kind of information that is required to satisfy the request. They are defined by local agreement between the inquiring system and the ancillary system. See the Implementation Guide for detailed examples of the use of query filter fields.

The Set ID fields in the various segments (including PID) are used to count the number of segments of one kind transmitted at one level of the hierarchy.

QRD-12-Query Results Level determines the amount of data requested. See Chapter 2, Section 5.10.5.3.12, _Query Results Level._

9.9 CONSENT INFORMATION

9.9.1 Short Description

This segment identifies patient consent information relating to a particular message. It can be used as part of existing messages to convey information about patient consent to procedures, admissions, information release/exchange or other events discussed by the message. It may also be used in messages focusing on recording or requesting consent and for consents related to employees or service providers.

The segment will be used in conjunction with various other segments to identify the practitioner (PRA/STF) or patient (PID) the consent is for, the various individuals involved in the consent (ROL) as witnesses, consenting person (not always the patient), translators, consulting providers, etc., and the specific procedures being proposed (PR1).

9.9.2 Justification

9.9.2.1 Segment

The issue of patient consent has become more important, particularly in the tracking of consent for the release of or exchange of information. The pieces of information recorded when dealing with a patient consent tend to be similar, regardless of the purpose of the consent. This segment combines these pieces of information so that they can be used for consents of any type.

9.9.2.2 Fields

Consent Type: In concert with giving consent, some programs may allow patients to request varying degrees of participation in a given program. I.e. if consent program relates to a patient_s entire medical record being available online they might have the opportunity to only reveal certain portions of that history such as the drug history only..

Consent Form ID: Some institutions may have a set of pre-defined consent forms. Identifying the specific form identifies the details the subject is consenting to, as well as what information is on the form.

Consent Text: When recording consents electronically it is important to know the specific text that was presented to the consenting person.

Subject-specific Consent Text: Sometimes consent forms have areas where details of the procedure or information distribution that are specific to a given consent instance are recorded, i.e. a variation on a common procedure, or an explicit listing of documents to be released. As this is part of the consent document, it needs to be recorded. It is helpful to keep this information separate from the standard _template_ consent text, as in most circumstances people viewing the consent will want to know _What_s different from usual_.

Background Text: In most cases in the health field, consent must be _informed_ consent. This means that the consenting individual must understand and appreciate the implications of what they are consenting to. Most consent processes involve providing background material describing the reasons for the proposed service, expected benefits and potential risks. It is important to have a record of what information was presented to the subject at the time of consent.

Subject-specific Background Text: The reasons, expected benefits and risks may vary from subject to subject. It may be necessary to inform the subject of background information that only applies to their particular circumstance.

Subject-imposed Limitations: At the time of consent, the subject may wish to make modifications or add limitations to their consent. These modifications and limitations must be recorded.

Consent Mode: The manner in which consent can be given may vary greatly within a specific program, from program to program, or from organization to organization. Therefore, the standard must allow applications to identify how consent was obtained (i.e. verbally, written, etc.).

Consent Status: Consent can be pending (subject hasn_t been asked yet), given, refused, revoked or even completely bypassed. Consent Status identifies what the status of a subject_s consent is (or was at a given point in time).

Consent Discussion Date/Time: For informed consent, a knowledgeable person must discuss the ramifications of consent with the subject. In some instances, this discussion is required to take place prior to the provision of consent. This ensures that the subject has sufficient time to consider the ramifications of their decision. To ensure that guidelines are followed, it is imperative to record when the consent information was initially discussed with the subject.

Consent Decision Date/Time: Related to the above, there also needs to be a record of the time the subject actually made their consent decision.

Consent Effective Date/Time: Not all consents take effect at the time the consent decision is made. They may not become effective for some time, or in certain circumstances they may even be retroactive. Use this field to record the effective time. .

Consent End Date/Time: For most programs requiring voluntary participation, the decision to participate is not final and therefore may be revoked in the future. Therefore, when a patient makes the decision to revoke their consent, the date and time on which the decision was made must be recorded in order to provide a complete history of the consent. Alternatively, the initial consent may only have been granted for a limited period of time (i.e. 24 hours, 1 week, 1 year). If Consent End Date/Time is null, this should be interpreted as _indefinite_.

Subject Competence Indicator: One of the issues involved in informed consent is whether the subject is judged to be competent to provide consent on their own behalf. Factors involve age, mental capacity, and current state of health/awareness. A professional judgment about whether the subject is deemed competent must be made and recorded.

Translator Assistance Indicator: To obtain informed consent, the patient must understand what they are consenting to. For subjects who do not understand the commonly used language of the institution, or who are unable to hear/read/speak, translation services may be required.

Translation Type: To obtain informed consent, the patient must understand what they are consenting to. For subjects who do not understand the commonly used language of the institution, or who are unable to hear/read/speak, translation services may be required. An indication of what type(s) of translation were/will be performed is required.

Informational Material Supplied Indicator: As part of the informed consent process, additional material in the form of pamphlets, books, brochures, videos, etc. may be provided to the patient. An indication of whether this has been done is required. (Details on the materials provided will be sent using a separate segment.)

Consent Bypass Reason: There may arise situations in which an action must be performed without patient consent (i.e. retrieving an unconscious patient_s drug history, performing life saving surgery, etc.). This field indicates the rationale for accessing information without obtaining the required consent.

Consent Disclosure Level: Identifies whether the subject was provided with information on the full background information on the procedure, the subject is giving consent to, i.e. has all information needed for _informed_ consent been provided.

Consent Non-disclosure Reason: Identifies why information was withheld from the patient (i.e. telling the patient may cause a worse outcome than performing the procedure).

9.9.3 Use Case(s)

  1. A patient decides to participate in a voluntary electronic drug history program. The patient records this decision in writing (Consent Mode) on a pre-designed consent form (Consent Form ID and Version) after their health care service provider has explained the benefits and drawbacks of their participation. In providing consent, the patient can also decide on the degree to which they will participate in the program (Consent Type). The consent decision (Consent Status) is recorded under the patient_s name (use ROL segment) and the number of the paper-based form that the patient signed is recorded in the electronic consent gathering function (Consent Number). The patient_s consent is effective from the day of the decision (Consent Effect Date/Time), but this consent can be terminated at the patient_s discretion at a given date in the future (Consent End Date/Time). Several months later the patient is rushed into an emergency health care facility with what appears to be a drug reaction. While checking the patient_s drug history, health care service providers find that the patient_s drug history has controlled access. The patient is unable to provide access to this information given their physical state, so the health care service provider circumvents the consent process (Non-consent Access Reason) in the interests of the patient_s immediate well-being.

  2. A patient is seeking a therapeutic abortion. Because she is under 18, the practitioner must evaluate her competence to provide consent. The patient is deemed to be competent (Patient Competence Indicator). Local legislation mandates that the patient be counseled at least 24 hours prior to receiving the procedure. The patient is counseled, and the time recorded (Consent Discussion Date/Time). They are also given a pamphlet to take home and read (Informational Material Supplied Indicator). They return the following day and sign the consent form (Consent Decision Date/Time)

  3. A deaf patient is admitted for labor and delivery. It becomes apparent the patient will require a cesarean section. A translator is required (Translator Assistance Indicator) who can translate sign language (Translation Type). The translator explains the details of the procedure the patient is being asked to consent to (Consent Text), the intention to use epidural anesthetic (Subject-specific Consent Text), the general risks associated with doing the procedure, as well as those with not doing the procedure (Background Text) and benefits associated with the epidural (Subject-specific Background Text). The patient agrees to the procedure, subject to the condition that she not be given any blood products for religious reasons (Subject-imposed Limitations).

  4. An employee signs a consent form authorizing (Consent Status) a hospital to request their driving records from the local Department of Motor Vehicles (Consent Type).

  5. A patient signs a consent form to have basic diagnostic and billing information sent to their insurer. The consent indicates that information may only be given to parties that are bound by HIPPA guidelines (Trust Agreement Restriction Type)

9.9.4 CON _ Consent Segment

The consent segment provides details about a specific consent by a patient or staff member.

HL7 Attribute Table _ CON _Consent Segment

SEQ LEN DT OPT RP/# TBL# ITEM# ELEMENT NAME DB Ref.
1 4 SI R

01776 Set ID - CON DB
2 250 CWE O
0496 01777 Consent Type DB
3 40 ST O

01778 Consent Form ID DB
4 180 EI O

01779 Consent Form Number DB
5 64K FT O Y
01780 Consent Text DB
6 64K FT O Y
01781 Subject-specific Consent Text DB
7 64K FT O Y
01782 Consent Background DB
8 64K FT O Y
01783 Subject-specific Consent Background DB
9 64K FT O Y
01784 Consenter-imposed limitations DB
10 2 CNE O
0497 01785 Consent Mode DB
11 2 CNE R
0498 01786 Consent Status DB
12 26 TS O

01787 Consent Discussion Date/Time DB
13 26 TS O

01788 Consent Decision Date/Time DB
14 26 TS O

01789 Consent Effective Date/Time DB
15 26 TS O

01790 Consent End Date/Time DB
16 1 ID O
0136 01791 Subject Competence Indicator DB
17 1 ID O
0136 01792 Translator Assistance Indicator DB
18 1 ID O
0296 01793 Language Translated To DB
19 1 ID O
0136 01794 Informational Material Supplied Indicator DB
20 250 CWE O
0499 01795 Consent Bypass Reason DB
21 1 ID O
0500 01796 Consent Disclosure Level DB
22 250 CWE O
0501 01797 Consent Non-disclosure Reason DB
23 250 CWE O
0502 01798 Non-subject Consenter Reason DB
24 250 XPN R Y
01909 Consenter ID DB
25 100 IS R Y 0548 01898 Relationship to Subject Table DB

9.9.4.0 CON Segment Field Definitions

9.9.4.1 CON-1 Set ID (SI) 01776

Definition: This field contains the number that identifies this segment instance within the message. For the first occurrence of the segment, the sequence number shall be one, for the second occurrence, the sequence number shall be two, etc.

9.9.4.2 CON-2 Consent Type (CWE) 01777

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

Definition: This field describes what the subject is consenting to, i.e. what type of service, surgical procedure, information access/release or other event. For values see User-Defined Table 0496 _ Consent Type.

User Defined Table 0496 _ Consent Type

Value Description Comment
001 Release of Information/MR / Authorization to Disclosure Protected Health Information Release of Info/ Disclosure
002 Medical Procedure (invasive) Medical Treatment/ Procedure
003 Acknowledge Receipt of Privacy Notice Acknowledgement/ Notification
004 Abortion Medical Treatment/ Procedure
005 Abortion/Laminaria Medical Treatment/ Procedure
006 Accutane _ Information Medical Treatment/ Procedure
007 Accutane _ Woman Medical Treatment/ Procedure
008 Advanced Beneficiary Notice Acknowledgement/ Notification
009 AFP (Alpha Fetoprotein) Screening Medical Treatment/ Procedure
010 Amniocentesis (consent & refusal) Medical Treatment/ Procedure
011 Anatomical Gift (organ donation) Administrative
012 Anesthesia - Complications Medical Treatment/ Procedure
013 Anesthesia - Questionnaire Medical Treatment/ Procedure
014 Angiogram Medical Treatment/ Procedure
015 Angioplasty Medical Treatment/ Procedure
016 Anticancer Drugs Medical Treatment/ Procedure
017 Antipsychotic Medications Medical Treatment/ Procedure
018 Arthrogram Medical Treatment/ Procedure
019 Autopsy Administrative
020 AZT Therapy Medical Treatment/ Procedure
021 Biliary Drainage Medical Treatment/ Procedure
022 Biliary Stone Extraction Medical Treatment/ Procedure
023 Biopsy Medical Treatment/ Procedure
024 Bleeding Time Test Medical Treatment/ Procedure
025 Bronchogram Medical Treatment/ Procedure
026 Cardiac Catheterization Medical Treatment/ Procedure
027 Coronary Angiography Medical Treatment/ Procedure
028 "" "" w/o Surgery Capability Medical Treatment/ Procedure
029 Cataract Op/Implant of FDA Aprvd Lens Medical Treatment/ Procedure
030 Cataract Op/Implant of Investigational Lens Medical Treatment/ Procedure
031 Cataract Surgery Medical Treatment/ Procedure
032 Cholera Immunization Medical Treatment/ Procedure
033 Cholesterol Screening Medical Treatment/ Procedure
034 Circumcision _ Newborn Medical Treatment/ Procedure
035 Colonoscopy Medical Treatment/ Procedure
036 Contact Lenses Medical Treatment/ Procedure
037 CT Scan - Cervical & Lumbar Medical Treatment/ Procedure
038 CT Scan w/ IV Contrast Media into Vein Medical Treatment/ Procedure
039 CVS (Chorionic Villus) Sampling Medical Treatment/ Procedure
040 Cystospy Medical Treatment/ Procedure
041 Disclosure of Protected Health Information to Family/Friends Release of Info/ Disclosure
042 D & C and Conization Medical Treatment/ Procedure
043 Dacryocystogram Medical Treatment/ Procedure
044 Diagnostic Isotope Medical Treatment/ Procedure
045 Drainage of an Abscess Medical Treatment/ Procedure
046 Drug Screening Medical Treatment/ Procedure
047 Electronic Monitoring of Labor - Refusal Medical Treatment/ Procedure
048 Endometrial Biopsy Medical Treatment/ Procedure
049 Endoscopy/Sclerosis of Esophageal Varices Medical Treatment/ Procedure
050 ERCP Medical Treatment/ Procedure
051 Exposure to reportable Communicable Disease Medical Treatment/ Procedure
052 External Version Medical Treatment/ Procedure
053 Fluorescein Angioscopy Medical Treatment/ Procedure
054 Hepatitis B - Consent/Declination Medical Treatment/ Procedure
055 Herniogram Medical Treatment/ Procedure
056 HIV Test - Consent Refusal Medical Treatment/ Procedure
057 HIV Test - Disclosure Medical Treatment/ Procedure
058 HIV Test - Prenatal Medical Treatment/ Procedure
059 Home IV Treatment Program Medical Treatment/ Procedure
060 Home Parenteral Treatment Program Medical Treatment/ Procedure
061 Hysterectomy Medical Treatment/ Procedure
062 Hysterosalpingogram Medical Treatment/ Procedure
063 Injection Slip/ Consent Medical Treatment/ Procedure
064 Intrauterine Device Medical Treatment/ Procedure
065 Intrauterine Device/Sterilization Medical Treatment/ Procedure
066 Intravascular Infusion of Streptokinase/Urokinase Medical Treatment/ Procedure
067 Intravenous Cholangiogram Medical Treatment/ Procedure
068 Intravenous Digital Angiography Medical Treatment/ Procedure
069 Iodine Administration Medical Treatment/ Procedure
070 ISG Medical Treatment/ Procedure
071 IVP Medical Treatment/ Procedure
072 Laser Photocoagulation Medical Treatment/ Procedure
073 Laser treatment Medical Treatment/ Procedure
074 Lithium Carbonate Medical Treatment/ Procedure
075 Liver Biopsy Medical Treatment/ Procedure
076 Lumbar Puncture Medical Treatment/ Procedure
077 Lymphangiogram Medical Treatment/ Procedure
078 MAO Inhibitors Medical Treatment/ Procedure
079 Med, Psych, and/or Drug/Alcohol Release of Info/ Disclosure
080 Medical Treatment - Refusal Administrative
081 Morning-after Pill Medical Treatment/ Procedure
082 MRI _ Adult Medical Treatment/ Procedure
083 MRI _ Pediatric Medical Treatment/ Procedure
084 Myelogram Medical Treatment/ Procedure
085 Needle Biopsy Medical Treatment/ Procedure
086 Needle Biopsy of Lung Medical Treatment/ Procedure
087 Newborn Treatment and Release Medical Treatment/ Procedure
088 Norplant Subdermal Birth Control Implant Medical Treatment/ Procedure
089 Operations, Anesthesia, Transfusions Medical Treatment/ Procedure
090 Oral Contraceptives Medical Treatment/ Procedure
091 Organ Donation Administrative
092 Patient Permits, Consents Administrative
093 Patient Treatment Permit, Release & Admission Administrative
094 Penile Injections Medical Treatment/ Procedure
095 Percutaneous Nephrostomy Medical Treatment/ Procedure
096 Percutaneous Transhepatic Cholangiogram Medical Treatment/ Procedure
097 Photographs Release of Info/ Disclosure
098 Photographs - Employee Release of Info/ Disclosure
099 Photographs - Medical Research Release of Info/ Disclosure
100 Photographs - news Media Release of Info/ Disclosure
101 Psychiatric Admission - Next of Kin Medical Treatment/ Procedure
102 Psychiatric Information During Hospital Stay Release of Info/ Disclosure
103 Public Release of Information Release of Info/ Disclosure
104 Radiologic Procedure Medical Treatment/ Procedure
105 Refusal of Treatment Administrative
106 Release of Body Administrative
107 Release of Limb Administrative
108 Rh Immune Globulin Medical Treatment/ Procedure
109 Rights of Medical Research Participants Administrative
110 Request to Restrict Access/Disclosure to Medical Record/Protected Health Information Release of Info/ Disclosure
111 Request for Remain Anonymous Release of Info/ Disclosure
112 Seat Belt Exemption Administrative
113 Sialogram Medical Treatment/ Procedure
114 Sigmoidoscopy Medical Treatment/ Procedure
115 Sterilization - Anesthesia & Medical Services Medical Treatment/ Procedure
116 Sterilization -Federally Funded Medical Treatment/ Procedure
117 Sterilization _ Female Medical Treatment/ Procedure
118 Sterilization - Laparoscopy/Pomeroy Medical Treatment/ Procedure
119 Sterilization - Non-Federally Funded Medical Treatment/ Procedure
120 Sterilization - Secondary Medical Treatment/ Procedure
121 Tranquilizers Medical Treatment/ Procedure
122 Transfer - Acknowledgement Medical Treatment/ Procedure
123 Transfer _ Authorization Medical Treatment/ Procedure
124 Transfer Certification - Physician Medical Treatment/ Procedure
125 Transfer/Discharge Request Medical Treatment/ Procedure
126 Transfer for Non-Medical Reasons Medical Treatment/ Procedure
127 Transfer - Interfaculty Neonatal Medical Treatment/ Procedure
128 Transfer Refusal Medical Treatment/ Procedure
129 Transfer Refusal of Further Treatment Medical Treatment/ Procedure
130 Treadmill & EKG Medical Treatment/ Procedure
131 Treadmill, Thallium-201 Medical Treatment/ Procedure
132 Typhoid Medical Treatment/ Procedure
133 Use of Investigational Device Medical Treatment/ Procedure
134 Use of Investigational Drug Medical Treatment/ Procedure
135 Venogram Medical Treatment/ Procedure
136 Videotape Release of Info/ Disclosure
1137 Voiding Cystogram Medical Treatment/ Procedure

9.9.4.3 CON-3 Consent Form ID and Version (ST) 01778

Definition: Identifies a specific version of a consent form used to record the consent. A given version of a consent form implies a particular set of wording that appears on the form.

9.9.4.4 CON-4 Consent Form Number (EI) 01779

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Entity Identifier (ST)> ^ <Namespace ID (IS)> ^ <Universal ID (ST)> ^ <Universal ID Type (ID)>

Definition: Uniquely identifies a specific recorded consent. This may be the number assigned to an electronic consent, or may be the number on a printed consent form.

9.9.4.5 CON-5 Consent Text (FT) 01780

Definition: Describes the specific procedures/information releases/events the subject is consenting to.

9.9.4.6 CON-6 Subject-specific Consent Text (FT) 01781

Definition: Describes any additions or variations to the standard procedures/information releases/events from a standard consent that are applicable to the subject whose consent is sought.

9.9.4.7 CON-7 Background Text (FT) 01782

Definition: Describes any additional information relating to the procedure/information release/event that needs to be understood by the subject for informed consent. May include the reason for the service, the expected benefit, risks, etc.

9.9.4.8 CON-8 Subject-specific Background Text (FT) 01783

Definition: Describes any additions or variations to the standard additional information that needs to be understood by the patient for informed consent. May include a description of benefits and risks that are specific to the subject from whom consent is sought. May also include an indication that there are no subject-specific risks/benefits.

9.9.4.9 CON-9 Consenter-imposed Limitations (FT) 01784

Definition: Describes any restrictions or limitations placed on their consent by the subject.

9.9.4.10 CON-10 Consent Mode (CNE) 01785

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

Definition: The method in which a subject provides consent.

HL7 Table 0497 _ Consent Mode

Value Description Comment
V Verbal
W Written
T Telephone

9.9.4.11 CON-11 Consent Status (CNE) 01786

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

Definition: Indicates whether consent has been sought and granted.

HL7 Table 0498 _ Consent Status

Value Description Comment
A Active _ Consent has been granted
L Limited _ Consent has been granted with limitations
R Refused _ Consent has been refused
P Pending _ Consent has not yet been sought
X Rescinded _ Consent was initially granted, but was subsequently revoked or ended.
B Bypassed (Consent not sought)

9.9.4.12 CON-12 Consent Discussion Date/Time (TS) 01787

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: Identifies the time when consent was discussed with the subject. This should only be specified if this differs from the time the consent decision is made.

9.9.4.13 CON-13 Consent Decision Date/Time (TS) 01788

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: Identifies the time when the decision to grant/refuse consent was made. In the case of written consent, this is the time the consent form is signed.

9.9.4.14 CON-14 Consent Effective Date/Time (TS) 01789

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: The time the consent becomes/became effective. This only needs to be specified if the time differs from the Consent Decision Date/Time

9.9.4.15 CON-15 Consent End Date/Time (TS) 01790

Components: <Time (DTM)> ^ <DEPRECATED-Degree of Precision (ID)>

Definition: The time the consent becomes ineffective. If not specified, the consent is assumed to be indefinite. For consents relating to information release, the end date/time is the date by which the released information must be returned/destroyed.

9.9.4.16 CON-16 Subject Competent Indicator (ID) 01791

Definition: Identifies whether the subject was deemed competent to provide consent. Refer to table HL7 table 0136 _ Yes/No Indicator

9.9.4.17 CON-17 Translator Assistance Indicator (ID) 01792

Definition: Identifies whether translation was (or will be) required to obtain informed consent from the subject. Refer to table HL7 table 0136 _ Yes/No Indicator

9.9.4.18 CON-18 Language Translated To (ID) 01793

Definition: Identifies the language the consent material must be translated to. Refer to User-Defined Table 0545 _ Language Translated To for values. This table may be populated with values similar to those that may be found in ISO table 639 _ Language Codes.

User Defined Table 0545 _ Language Translated To

Value Description Comment

No Suggested values.

9.9.4.19 CON-19 Informational Material Supplied Indicator (ID) 01794

Definition: Identifies whether additional educational or reference material was provided to the subject as part of the consent process. Refer to table HL7 table 0136 _ Yes/No Indicator.

9.9.4.20 CON-20 Consent Bypass Reason (CWE) 01795

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

Definition: Identifies why the subject_s consent was not sought. This field must be populated when CON.11 (Consent Status) is B _ Bypassed.

User Defined Table 0499 _ Consent Bypass Reason

Value Description Comment
E Emergency
PJ Professional Judgment

9.9.4.21 CON-21 Consent Disclosure Level (ID) 01796

Definition: Identifies how much information was disclosed to the subject as part of the informed consent process.

HL7 Table 0500 _ Consent Disclosure Level

Value Description Comment
F Full Disclosure
P Partial Disclosure
N No Disclosure

9.9.4.22 CON-22 Consent Non-Disclosure Reason (CWE) 01797

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

Definition: Identifies why the subject did not receive full disclosure. .

User Defined Table 0501 _ Consent Non-Disclosure Reason

Value Description Comment
E Emergency
RX Rx Private
PR Patient Request

9.9.4.23 CON-23 Non-Subject Consenter Reason (CWE) 01798

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Identifier (ST)> ^ <Text (ST)> ^ <Name of Coding System (ID)> ^ <Alternate Identifier (ST)> ^ <Alternate Text (ST)> ^ <Name of Alternate Coding System (ID)> ^ <Coding System Version ID (ST)> ^ <Alternate Coding System Version ID (ST)> ^ <Original Text (ST)>

Definition: Identifies why consent was granted by a person other than the subject of the consent.

User Defined Table 0502 _ Non-Subject Consenter Reason

Value Description Comment
MIN Subject is a minor
NC Subject is not competent to consent
LM Legally mandated

9.9.4.24 CON-24 Consenter ID (XPN) 01909

Components: <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <DEPRECATED-Degree (e.g., MD) (IS)> ^ <Name Type Code (ID)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <DEPRECATED-Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for DEPRECATED-Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Note subcomponent contains sub-subcomponents

Subcomponents for Effective Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <DEPRECATED-Degree of Precision (ID)>

The component descriptions presented here are provided for readability. The implementer should treat the component descriptions in Chapter 2 as the definitive content.

Components: <Family Name (FN)> ^ <Given Name (ST)> ^ <Second and Further Given Names or Initials Thereof (ST)> ^ <Suffix (e.g., JR or III) (ST)> ^ <Prefix (e.g., DR) (ST)> ^ <Degree (e.g., MD) (IS)> ^ <Name Type Code (ID)> ^ <Name Representation Code (ID)> ^ <Name Context (CE)> ^ <Name Validity Range (DR)> ^ <Name Assembly Order (ID)> ^ <Effective Date (TS)> ^ <Expiration Date (TS)> ^ <Professional Suffix (ST)>

Subcomponents for Family Name (FN): <Surname (ST)> & <Own Surname Prefix (ST)> & <Own Surname (ST)> & <Surname Prefix From Partner/Spouse (ST)> & <Surname From Partner/Spouse (ST)>

Subcomponents for Name Context (CE): <Identifier (ST)> & <Text (ST)> & <Name of Coding System (ID)> & <Alternate Identifier (ST)> & <Alternate Text (ST)> & <Name of Alternate Coding System (ID)>

Subcomponents for Name Validity Range (DR): <Range Start Date/Time (TS)> & <Range End Date/Time (TS)>

Subcomponents for Range Start Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Range End Date/Time (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Effective Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Subcomponents for Expiration Date (TS): <Time (DTM)> & <Degree of Precision (ID)>

Definition: Identification of the individual(s) who are consenting.

9.9.4.25 CON-25 Relationship to Subject (IS) 01898

Definition: Identification of the relationship of the consenter to the subject.

User-Defined Table 0548 _ Signatory_s Relationship to Subject

Value Description Comment
1 Self
2 Parent
3 Next of Kin
4 Durable Power of Attorney in Healthcare Affairs
5 Conservator
6 Emergent Practitioner (practitioner judging case as emergency requiring care without a consent)
7 Non-Emergent Practitioner (i.e. medical ethics committee)

9.10 OUTSTANDING ISSUES

There are no messages that use the consent segment. The intention of the committee is to add messages regarding consent management in version 2.6.

This version of the standard clarifies the use of MDM message as opposed to ORU messages. Refer to Chapter 7.