Dictionary

Patient
ShortUS Core Patient Profile
Definition

The US Core Patient Profile is based upon the core FHIR Patient Resource and designed to meet the applicable patient demographic data elements from the 2015 Edition Common Clinical Data Set.

Cardinality0..*
TypeDomainResource
AliasSubjectOfCare Client Resident
Mappings
  • cda: ClinicalDocument.recordTarget.patientRole
  • rim: Patient[classCode=PAT]
  • w5: administrative.individual
  • argonaut-dq-dstu2: Patient
Patient.id
ShortLogical id of this artifact
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Cardinality0..1
Typeid
SummaryTrue
Patient.meta
ShortMetadata about the resource
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Cardinality0..1
TypeMeta
SummaryTrue
Patient.implicitRules
ShortA set of rules under which this content was created
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Cardinality0..1
Typeuri
ModifierTrue
SummaryTrue
Patient.language
ShortLanguage of the resource content
Definition

The base language in which the resource is written.

Cardinality0..1
Typecode
Binding

A human language.

http://tools.ietf.org/html/bcp47 (required)

Patient.text
ShortText summary of the resource, for human interpretation
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Cardinality0..1
TypeNarrative
Aliasnarrative, html, xhtml, display
ConditionsThe cardinality or value of this element may be affected by these constraints: dom-1
Mappings
  • rim: Act.text?
Patient.contained
ShortContained, inline Resources
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Cardinality0..*
TypeResource
Aliasinline resources, anonymous resources, contained resources
Mappings
  • rim: N/A
Patient.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Slicing

Unordered, Open, by url(Value)

Mappings
  • rim: N/A
Patient.extension:race
ShortUS Core Race Extension
Definition

Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The race codes used to represent these concepts are based upon the CDC Race and Ethnicity Code Set Version 1.0 which includes over 900 concepts for representing race and ethnicity of which 921 reference race. The race concepts are grouped by and pre-mapped to the 5 OMB race categories: - American Indian or Alaska Native - Asian - Black or African American - Native Hawaiian or Other Pacific Islander - White.

Cardinality0..1
TypeExtension
Must SupportTrue
Aliasextensions, user content
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    children().count() > id.count()
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
  • argonaut-dq-dstu2: Patient.extension
Patient.extension:ethnicity
ShortUS Core ethnicity Extension
Definition

Concepts classifying the person into a named category of humans sharing common history, traits, geographical origin or nationality. The ethnicity codes used to represent these concepts are based upon the CDC ethnicity and Ethnicity Code Set Version 1.0 which includes over 900 concepts for representing race and ethnicity of which 43 reference ethnicity. The ethnicity concepts are grouped by and pre-mapped to the 2 OMB ethnicity categories: - Hispanic or Latino - Not Hispanic or Latino.

Cardinality0..1
TypeExtension
Must SupportTrue
Aliasextensions, user content
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    children().count() > id.count()
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
  • argonaut-dq-dstu2: Patient.extension
Patient.extension:birthsex
ShortExtension
Definition

A code classifying the person's sex assigned at birth as specified by the Office of the National Coordinator for Health IT (ONC).

Cardinality0..1
TypeExtension
Binding

Code for sex assigned at birth

http://hl7.org/fhir/us/core/ValueSet/us-core-birthsex (required)

Must SupportTrue
Aliasextensions, user content
Comments

The codes required are intended to present birth sex (i.e., the sex recorded on the patient’s birth certificate) and not gender identity or reassigned sex.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    children().count() > id.count()
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/administrativeGender
  • iso11179: .patient.administrativeGenderCode
  • argonaut-dq-dstu2: Patient.extension
Patient.modifierExtension
ShortExtensions that cannot be ignored
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Cardinality0..*
TypeExtension
ModifierTrue
Aliasextensions, user content
Mappings
  • rim: N/A
Patient.identifier
ShortAn identifier for this patient
Definition

An identifier for this patient.

Cardinality1..*
TypeIdentifier
Must SupportTrue
SummaryTrue
Requirements

Patients are almost always assigned specific numerical identifiers.

Mappings
  • cda: .id
  • v2: PID-3
  • rim: id
  • w5: id
  • argonaut-dq-dstu2: Patient.identifier
Patient.active
ShortWhether this patient's record is in active use
Definition

Whether this patient record is in active use.

Cardinality0..1
Typeboolean
ModifierTrue
SummaryTrue
Requirements

Need to be able to mark a patient record as not to be used because it was created in error.

Default value
true
Mappings
  • cda: n/a
  • rim: statusCode
  • w5: status
Patient.name
ShortA name associated with the patient
Definition

A name associated with the individual.

Cardinality1..*
TypeHumanName
Must SupportTrue
SummaryTrue
Requirements

Need to be able to track the patient by multiple names. Examples are your official name and a partner name.

Mappings
  • cda: .patient.name
  • v2: PID-5, PID-9
  • rim: name
  • argonaut-dq-dstu2: Patient.name
Patient.telecom
ShortA contact detail for the individual
Definition

A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted.

Cardinality0..*
TypeContactPoint
SummaryTrue
Requirements

People have (primary) ways to contact them in some way such as phone, email.

Mappings
  • cda: .telecom
  • v2: PID-13, PID-14, PID-40
  • rim: telecom
Patient.gender
Shortmale | female | other | unknown
Definition

Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes.

Cardinality1..1
Typecode
Binding

The gender of a person used for administrative purposes.

AdministrativeGender (required)

Must SupportTrue
SummaryTrue
Requirements

Needed for identification of the individual, in combination with (at least) name and birth date. Gender of individual drives many clinical processes.

Mappings
  • cda: .patient.administrativeGenderCode
  • v2: PID-8
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/administrativeGender
  • argonaut-dq-dstu2: Patient.gender
Patient.birthDate
ShortThe date of birth for the individual
Definition

The date of birth for the individual.

Cardinality0..1
Typedate
Must SupportTrue
SummaryTrue
Requirements

Age of the individual drives many clinical processes.

Mappings
  • loinc: 21112-8
  • cda: .patient.birthTime
  • v2: PID-7
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/birthTime
  • argonaut-dq-dstu2: Patient.birthDate
Patient.deceased[x]
ShortIndicates if the individual is deceased or not
Definition

Indicates if the individual is deceased or not.

Cardinality0..1
Typeboolean, dateTime
ModifierTrue
SummaryTrue
Requirements

The fact that a patient is deceased influences the clinical process. Also, in human communication and relation management it is necessary to know whether the person is alive.

Mappings
  • cda: n/a
  • v2: PID-30 (bool) and PID-29 (datetime)
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/deceasedInd, player[classCode=PSN|ANM and determinerCode=INSTANCE]/deceasedTime
Patient.address
ShortAddresses for the individual
Definition

Addresses for the individual.

Cardinality0..*
TypeAddress
SummaryTrue
Requirements

May need to keep track of patient addresses for contacting, billing or reporting requirements and also to help with identification.

Mappings
  • cda: .addr
  • v2: PID-11
  • rim: addr
Patient.maritalStatus
ShortMarital (civil) status of a patient
Definition

This field contains a patient's most recent marital (civil) status.

Cardinality0..1
TypeCodeableConcept
Binding

The domestic partnership status of a person.

Marital Status Codes (required)

Requirements

Most, if not all systems capture it.

Mappings
  • cda: .patient.maritalStatusCode
  • v2: PID-16
  • rim: player[classCode=PSN]/maritalStatusCode
Patient.multipleBirth[x]
ShortWhether patient is part of a multiple birth
Definition

Indicates whether the patient is part of a multiple or indicates the actual birth order.

Cardinality0..1
Typeboolean, integer
Requirements

For disambiguation of multiple-birth children, especially relevant where the care provider doesn't meet the patient, such as labs.

Mappings
  • cda: n/a
  • v2: PID-24 (bool), PID-25 (integer)
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/multipleBirthInd, player[classCode=PSN|ANM and determinerCode=INSTANCE]/multipleBirthOrderNumber
Patient.photo
ShortImage of the patient
Definition

Image of the patient.

Cardinality0..*
TypeAttachment
Requirements

Many EHR systems have the capability to capture an image of the patient. Fits with newer social media usage too.

Mappings
  • cda: n/a
  • v2: OBX-5 - needs a profile
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/desc
Patient.contact
ShortA contact party (e.g. guardian, partner, friend) for the patient
Definition

A contact party (e.g. guardian, partner, friend) for the patient.

Cardinality0..*
TypeBackboneElement
Requirements

Need to track people you can contact about the patient.

Constraints
  • pat-1: SHALL at least contain a contact's details or a reference to an organization
Mappings
  • cda: n/a
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/scopedRole[classCode=CON]
Patient.contact.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references).

Cardinality0..1
Typeid
Mappings
  • rim: n/a
Patient.contact.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Mappings
  • rim: n/a
Patient.contact.modifierExtension
ShortExtensions that cannot be ignored
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Cardinality0..*
TypeExtension
ModifierTrue
Aliasextensions, user content, modifiers
Mappings
  • rim: N/A
Patient.contact.relationship
ShortThe kind of relationship
Definition

The nature of the relationship between the patient and the contact person.

Cardinality0..*
TypeCodeableConcept
Binding

The nature of the relationship between a patient and a contact person for that patient.

http://hl7.org/fhir/ValueSet/patient-contact-relationship (extensible)

Requirements

Used to determine which contact person is the most relevant to approach, depending on circumstances.

Mappings
  • cda: n/a
  • v2: NK1-7, NK1-3
  • rim: code
Patient.contact.name
ShortA name associated with the contact person
Definition

A name associated with the contact person.

Cardinality0..1
TypeHumanName
Requirements

Contact persons need to be identified by name, but it is uncommon to need details about multiple other names for that contact person.

Mappings
  • cda: n/a
  • v2: NK1-2
  • rim: name
Patient.contact.telecom
ShortA contact detail for the person
Definition

A contact detail for the person, e.g. a telephone number or an email address.

Cardinality0..*
TypeContactPoint
Requirements

People have (primary) ways to contact them in some way such as phone, email.

Mappings
  • cda: n/a
  • v2: NK1-5, NK1-6, NK1-40
  • rim: telecom
Patient.contact.address
ShortAddress for the contact person
Definition

Address for the contact person.

Cardinality0..1
TypeAddress
Requirements

Need to keep track where the contact person can be contacted per postal mail or visited.

Mappings
  • cda: n/a
  • v2: NK1-4
  • rim: addr
Patient.contact.gender
Shortmale | female | other | unknown
Definition

Administrative Gender - the gender that the contact person is considered to have for administration and record keeping purposes.

Cardinality0..1
Typecode
Binding

The gender of a person used for administrative purposes.

AdministrativeGender (required)

Requirements

Needed to address the person correctly.

Mappings
  • cda: n/a
  • v2: NK1-15
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/administrativeGender
Patient.contact.organization
ShortOrganization that is associated with the contact
Definition

Organization on behalf of which the contact is acting or for which the contact is working.

Cardinality0..1
TypeOrganization()
Requirements

For guardians or business related contacts, the organization is relevant.

ConditionsThe cardinality or value of this element may be affected by these constraints: pat-1
Mappings
  • cda: n/a
  • v2: NK1-13, NK1-30, NK1-31, NK1-32, NK1-41
  • rim: scoper
Patient.contact.period
ShortThe period during which this contact person or organization is valid to be contacted relating to this patient
Definition

The period during which this contact person or organization is valid to be contacted relating to this patient.

Cardinality0..1
TypePeriod
Mappings
  • cda: n/a
  • rim: effectiveTime
Patient.animal
ShortThis patient is known to be an animal (non-human)
Definition

This patient is known to be an animal.

Cardinality0..0
TypeBackboneElement
SummaryTrue
Requirements

Many clinical systems are extended to care for animal patients as well as human.

Mappings
  • cda: n/a
  • rim: player[classCode=ANM]
  • argonaut-dq-dstu2: Patient.animal
Patient.animal.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references).

Cardinality0..1
Typeid
Mappings
  • rim: n/a
Patient.animal.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Mappings
  • rim: n/a
Patient.animal.modifierExtension
ShortExtensions that cannot be ignored
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Cardinality0..*
TypeExtension
ModifierTrue
Aliasextensions, user content, modifiers
Mappings
  • rim: N/A
Patient.animal.species
ShortE.g. Dog, Cow
Definition

Identifies the high level taxonomic categorization of the kind of animal.

Cardinality1..1
TypeCodeableConcept
Binding

The species of an animal.

AnimalSpecies (example)

SummaryTrue
Requirements

Need to know what kind of animal.

Mappings
  • cda: n/a
  • v2: PID-35
  • rim: code
Patient.animal.breed
ShortE.g. Poodle, Angus
Definition

Identifies the detailed categorization of the kind of animal.

Cardinality0..1
TypeCodeableConcept
Binding

The breed of an animal.

AnimalBreeds (example)

SummaryTrue
Requirements

May need to know the specific kind within the species.

Mappings
  • cda: n/a
  • v2: PID-37
  • rim: playedRole[classCode=GEN]/scoper[classCode=ANM, determinerCode=KIND]/code
Patient.animal.genderStatus
ShortE.g. Neutered, Intact
Definition

Indicates the current state of the animal's reproductive organs.

Cardinality0..1
TypeCodeableConcept
Binding

The state of the animal's reproductive organs.

GenderStatus (example)

SummaryTrue
Requirements

Gender status can affect housing and animal behavior.

Mappings
  • cda: n/a
  • v2: N/A
  • rim: genderStatusCode
Patient.communication
ShortA list of Languages which may be used to communicate with the patient about his or her health
Definition

Languages which may be used to communicate with the patient about his or her health.

Cardinality0..*
TypeBackboneElement
Must SupportTrue
Requirements

If a patient does not speak the local language, interpreters may be required, so languages spoken and proficiency is an important things to keep track of both for patient and other persons of interest.

Mappings
  • cda: patient.languageCommunication
  • rim: LanguageCommunication
  • argonaut-dq-dstu2: Patient.communication
Patient.communication.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references).

Cardinality0..1
Typeid
Mappings
  • rim: n/a
Patient.communication.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Mappings
  • rim: n/a
Patient.communication.modifierExtension
ShortExtensions that cannot be ignored
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Cardinality0..*
TypeExtension
ModifierTrue
Aliasextensions, user content, modifiers
Mappings
  • rim: N/A
Patient.communication.language
ShortThe language which can be used to communicate with the patient about his or her health
Definition

The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England English.

Cardinality1..1
TypeCodeableConcept
Binding

A human language.

http://hl7.org/fhir/us/core/ValueSet/simple-language (extensible)

Binding extensions
maxValueSethttp://hl7.org/fhir/us/core/ValueSet/simple-language
Must SupportTrue
Requirements

Most systems in multilingual countries will want to convey language. Not all systems actually need the regional dialect.

Mappings
  • cda: .languageCode
  • v2: PID-15, LAN-2
  • rim: player[classCode=PSN|ANM and determinerCode=INSTANCE]/languageCommunication/code
  • argonaut-dq-dstu2: Patient.communication.language
Patient.communication.preferred
ShortLanguage preference indicator
Definition

Indicates whether or not the patient prefers this language (over other languages he masters up a certain level).

Cardinality0..1
Typeboolean
Requirements

People that master multiple languages up to certain level may prefer one or more, i.e. feel more confident in communicating in a particular language making other languages sort of a fall back method.

Mappings
  • cda: .preferenceInd
  • v2: PID-15
  • rim: preferenceInd
Patient.careProvider
ShortPatient's nominated primary care provider
Definition

Patient's nominated care provider.

Cardinality0..*
TypeOrganization( | )
Mappings
  • cda: n/a
  • v2: PD1-4
  • rim: subjectOf.CareEvent.performer.AssignedEntity
Patient.managingOrganization
ShortOrganization that is the custodian of the patient record
Definition

Organization that is the custodian of the patient record.

Cardinality0..1
TypeOrganization()
SummaryTrue
Requirements

Need to know who recognizes this patient record, manages and updates it.

Mappings
  • cda: .providerOrganization
  • rim: scoper
Patient.link
ShortLink to another patient resource that concerns the same actual person
Definition

Link to another patient resource that concerns the same actual patient.

Cardinality0..*
TypeBackboneElement
ModifierTrue
Requirements

There are multiple usecases: * Duplicate patient records due to the clerical errors associated with the difficulties of identifying humans consistently, and * Distribution of patient information across multiple servers.

Mappings
  • cda: n/a
  • rim: outboundLink
Patient.link.id
Shortxml:id (or equivalent in JSON)
Definition

unique id for the element within a resource (for internal references).

Cardinality0..1
Typeid
Mappings
  • rim: n/a
Patient.link.extension
ShortAdditional Content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Mappings
  • rim: n/a
Patient.link.modifierExtension
ShortExtensions that cannot be ignored
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Cardinality0..*
TypeExtension
ModifierTrue
Aliasextensions, user content, modifiers
Mappings
  • rim: N/A
Patient.link.other
ShortThe other patient resource that the link refers to
Definition

The other patient resource that the link refers to.

Cardinality1..1
TypePatient()
ModifierTrue
Mappings
  • cda: n/a
  • v2: PID-3, MRG-1
  • rim: id
Patient.link.type
Shortreplace | refer | seealso - type of link
Definition

The type of link between this patient resource and another patient resource.

Cardinality1..1
Typecode
Binding

The type of link between this patient resource and another patient resource.

LinkType (required)

ModifierTrue
Mappings
  • cda: n/a
  • rim: typeCode