An ELEMENT to represent the clinical nature of a diagnosis5.
Diagnoses are decisions about the nature of a condition arrived at as a result of a synthesis of signs, symptoms, investigations
(i.e. findings), and theoretical knowledge. Conditions that may be diagnoses include diseases, disorders, syndromes and physiological
states such as pregnancy5.
The recording of a Diagnosis should be seen as being true at a particular point in time. A Care Professional will make a Diagnosis
using the information available at that time. Diagnoses will potentially progress over time as new information becomes available2.
In common with other finding observations, a Diagnosis Name is intended to fully represent the clinically relevant
nature of a clinical finding. It is distinguished as a diagnosis of a particular type by its link to a Diagnosis Tag.
A Diagnosis Name may be associated with more than one Diagnosis Tag(s). For example, a provisional working diagnosis
may subsequently be ascribed the status of primary diagnosis5.
2: NPFIT-NCR-DES-0135.07 NHS Care Record Elements
5: NPFIT-FNT-TO-DPM-0931.05 SNOMED CT Bindings for Common Recording Patterns
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): FINDING_OBSERVATION_ELEMENT |
|
|
rc_id
|
II.Uuid
|
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
|
1..1 |
A coded representation of the diagnosis. |
|
|
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.
|
|
|
policy_ids
|
II
|
0..* |
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.
|
|
|
obs_time
|
IVL_TS
|
0..1 |
The date and time, or interval, at which the diagnosis held. |
|
|
value
|
ANY
|
1..1 |
An ELEMENT has a single DATA_VALUE containing the value, unless this is indicated as absent by a null_flavour attribute. |
| nullFlavor |
| Literal value(s): NA |
|
COMPONENT RELATIONSHIPS
Subject of relationships
Object of relationships
Item of ENTRY Domain Models
Reference Model Type
