A constrained ENTRY containing a collection of data items required to represent a diagnosis that is present at the time of discharge as well as any diagnoses that were resolved during this admission of the subject of care.. Comprises a single coded Diagnosis and optionally may contain:

• a textual description of the event

• a coded representation of any medication activities that may be an indication for the diagnosis
• a coded representation of any procedure or diagnosis that may be a complication for a diagnosis
• a coded representation of any other problem and/or issue that may be a complication or problem presentation
• a coded representation of the diagnosis status represented currently with the help of temporary SNOMED CT concept identifiers for use within LRA only.

Specializes

Diagnosis

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): ENTRY
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.
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
uncertainty_expressed	BL	1..1	This attribute is set to TRUE to advise the EHR Recipient that this ENTRY contains data that indicates some degree of uncertainty, and that care should be taken when using these data within automated processes and systems.	nullFlavor Literal value(s): NA

Contained ELEMENTs

Graphical Representation

Subject ELEMENT class				Related object classes
Name	ELEMENT Class	Occurs	Description	Relationship	Occurs	Class	Dependency
items	DiagnosisStatus	0 .. *
items	Text	0 .. *
items	ProcedureActivity	0 .. *		IsComplicatedBy	0..*	ProcedureActivity FindingObservation	INDEPENDENT
				HasIndication	0..*	Diagnosis FindingObservation CareIssues	INDEPENDENT
				IsIndicationOf	0..*	StoppedMedicationActivity CurrentMedicationActivity	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
				Complicates	0..*	Diagnosis	INDEPENDENT
items	StoppedMedicationActivity	0 .. *		HasRecordRole	0..*	StoppedMedicationReconciliationStatus	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
				HasTemporalContext	0..*	StoppedMedicationActivity	INDEPENDENT
				IsComponentActionOf	0..*	StoppedMedicationActivity TreatmentActivity	INDEPENDENT
				HasPredecessor	1..*	CurrentMedicationActivity	INDEPENDENT
				HasIndication	0..*	ReasonForStoppingMedicationText ProcedureActivity FindingObservation PropertyObservation AllergiesOrAdverseReactionEvent StoppedMedicationActivity InvestigationActivity Diagnosis CareIssues TreatmentActivity	INDEPENDENT
items	CareIssues	0 .. *		IsClinicalContextOf	0..*	AdmissionEvent	INDEPENDENT
				HasRecordRole	0..*	ProblemsAndComplaintsTag	INDEPENDENT
				HasClinicalContext	0..*	ProcedureActivity Diagnosis FindingObservation	INDEPENDENT
				IsIndicationOf	0..*	StoppedMedicationActivity CurrentMedicationActivity	INDEPENDENT
				IsMotivationOf	0..*	ProcedureActivity AdmissionEvent	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
items	Diagnosis	1		IsComplicatedBy	0..*	Diagnosis ProcedureActivity	INDEPENDENT
				IsClinicalContextOf	0..*	CareIssues	INDEPENDENT
				IsIndicationOf	0..*	CurrentMedicationActivity StoppedMedicationActivity	INDEPENDENT
				HasRecordRole	0..1	DiagnosisStatus	INDEPENDENT
				HasAnnotation	0..*	Text	INDEPENDENT
items	CurrentMedicationActivity	0 .. *		HasTemporalContext	0..*	MedicationFutureCourseTiming MedicationCourseTiming	INDEPENDENT
				HasRecordRole	0..*	CurrentMedicationReconciliationStatus	INDEPENDENT
				HasTemporalContext	0..*	CurrentMedicationActivity	INDEPENDENT
				HasParameterSetting	0..*	DoseQuantity	INDEPENDENT
				AssertsTiming	0..*	EventDoseFrequency MeasuredDoseFrequency MedicationReviewText	INDEPENDENT
				Consumes	1..*	MedicinalProductOrSubstance	INDEPENDENT
				HasAnnotation	0..*	DosageInstructions	INDEPENDENT
				UsesDevice	0..*	MedicinalDevice ComplianceDevice	INDEPENDENT
				IsProspectOf	1..*	MedicationRecommendationActivity	INDEPENDENT
				IsPrecedentOf	1..*	StoppedMedicationActivity	INDEPENDENT
				HasAnnotation	0..*	DosageInstructions AdditionalInstructions	INDEPENDENT
				HasIndication	0..*	AllergiesOrAdverseReactionEvent TreatmentActivity InvestigationActivity FindingObservation CurrentMedicationActivity ReasonForMedicationText PropertyObservation ProcedureActivity CareIssues Diagnosis	INDEPENDENT
				IsComponentActionOf	0..*	CurrentMedicationActivity TreatmentActivity	INDEPENDENT
				HasComponentAction	0..*	MedicationReviewActivity	INDEPENDENT

Participations

Other Participations

Name	Class	Occurs	Description
other_participations	DiagnosisResponsibilityChoice	0..1	Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in an ENTRY. The ROLE class shall participate as a non-specific 'other participation' representing the person who is responsible for making the diagnosis about the subject of care.

Content of COMPOSITION Models

DischargeSummary

Reference Model Type

ENTRY