Logical Record Architecture for Health and Social Care

Discharge Summary Release 0.02

The content of this release is not comprehensive and is not fully validated and must not be used in live system implementations.

ELEMENT Domain Model: CapillaryRefillTimeObservation

An ELEMENT to represent the observation of a patient's capillary refill time

Attributes

Name Data type Occurs Description Value Constraints
name SC 1..1 The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR node corresponds, as labelled in the EHR system in which it was first committed.

value
Literal value(s): PROPERTY_OBSERVATION_ELEMENT
archetype_id ST 0..1 The unique identifier of the archetype node to which this RECORD_COMPONENT corresponds, either in the EHR Provider system or as a mapping produced when this EHR_EXTRACT was created. The syntax for populating this attribute value is defined in EN 13606-2:2008. Within the LRA the value assigned to this attribute SHALL have no effect on the interpretation of instances of this class and the attribute SHALL not be used as a predicate for semantic data retrieval.
rc_id II 1..1 The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently included in another EHR_EXTRACT.
meaning CD.CV.SCT 1..1 The standardised clinical or administrative concept to which the name attribute has been mapped. In archetyped systems it will correspond to the archetype node name. In non-archetyped systems it might be a coded term from an appropriate terminology system.

code
Semantic expression constraint
synthesised BL 1..1 This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted.

value
Default value: false
policy_ids II 0..1 This attribute identifies one or more access control policies that specifically pertain to this RECORD_COMPONENT and which need to be communicated to the EHR Recipient to govern future access to it. The identifiers may refer to policy information included in this EHR_EXTRACT as defined in EN 13606-4:2007, or to policies held in external policy servers to which the EHR Recipient has access.
sensitivity INT 0..1 The sensitivity of this RECORD_COMPONENT, represented using the code set for this attribute defined in EN 13606-4:2007.
orig_parent_ref II 0..1 The identity of the RECORD_COMPONENT that is the original parent (context) for this RECORD_COMPONENT, to be present if this information has been copied from another part of the EHR of this subject of care..
obs_time IVL_TS 0..1 The date and time, or interval, at which the ITEM actually occurred or was true, if different from the session time of the COMPOSITION.
value PQ 1..1 capillary refill time is measured in units. No specific UCUM unit can be assigned.

unit
Literal value(s): s


COMPONENT RELATIONSHIPS

Object of relationships

Name Subject of relationship Occurs Dependency
HasIndication GenericTreatment 0..* INDEPENDENT

Item of ENTRY Domain Models

CapillaryRefillTime

GenericTreatment

Diagnosis

Reference Model Type

PROPERTY_OBSERVATION_ELEMENT