Terminology

CodeSystem:AdverseEventCausalityAssessment

TODO.
CodeDisplayDefinition
CertainCertaini) Event or laboratory test abnormality, with plausible time relationship to drug intake ii) Cannot be explained by disease or other drugs iii) Response to withdrawal plausible (pharmacologically, pathologically) iv) Event definitive pharmacologically or phenomenologically (i.e. an objective and specific medical disorder or a recognized pharmacological phenomenon) v) Re-challenge satisfactory, if necessary.
Probably-LikelyProbably/Likelyi) Event or laboratory test abnormality, with reasonable time relationship to drug intake ii) Unlikely to be attributed to disease or other drugs iii) Response to withdrawal clinically reasonable iv) Re-challenge not required.
PossiblePossiblei) Event or laboratory test abnormality, with reasonable time relationship to drug intake ii) Could also be explained by disease or other drugs iii) Information on drug withdrawal may be lacking or unclear.
UnlikelyUnlikelyi) Event or laboratory test abnormality, with a time to drug intake that makes a relationship improbable (but not impossible) ii) Disease or other drugs provide plausible explanations.
Conditional-ClassifiedConditional/Classifiedi) Event or laboratory test abnormality ii) More data for proper assessment needed, or iii) Additional data under examination.
Unassessable-UnclassifiableUnassessable/Unclassifiablei) Report suggesting an adverse reaction ii) Cannot be judged because information is insufficient or contradictory iii) Data cannot be supplemented or verified.

CodeSystem:FamilyHistoryStatus

A code that identifies the status of the family history record.
CodeDisplayDefinition
partialPartialSome health information is known and captured, but not complete - see notes for details.
completedCompletedAll available related health information is captured as of the date (and possibly time) when the family member history was taken.
entered-in-errorEntered in errorThis instance should not have been part of this patient's medical record.
health-unknownHealth unknownHealth information for this individual is unavailable/unknown.

CodeSystem:CareTeamStatus

Indicates the status of the care team.
CodeDisplayDefinition
proposedProposedThe care team has been drafted and proposed, but not yet participating in the coordination and delivery of care.
activeActiveThe care team is currently participating in the coordination and delivery of care.
suspendedSuspendedThe care team is temporarily on hold or suspended and not participating in the coordination and delivery of care.
inactiveInactiveThe care team was, but is no longer, participating in the coordination and delivery of care.
entered-in-errorEntered In ErrorThe care team should have never existed.

CodeSystem:RequestStatus

Codes identifying the lifecycle stage of a request.
CodeDisplayDefinition
draftDraftThe request has been created but is not yet complete or ready for action.
activeActiveThe request is in force and ready to be acted upon.
on-holdOn HoldThe request (and any implicit authorization to act) has been temporarily withdrawn but is expected to resume in the future.
revokedRevokedThe request (and any implicit authorization to act) has been terminated prior to the known full completion of the intended actions. No further activity should occur.
completedCompletedThe activity described by the request has been fully performed. No further activity will occur.
entered-in-errorEntered in ErrorThis request should never have existed and should be considered 'void'. (It is possible that real-world decisions were based on it. If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".).
unknownUnknownThe authoring/source system does not know which of the status values currently applies for this request. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which.

CodeSystem:FlagStatus

Indicates whether this flag is active and needs to be displayed to a user, or whether it is no longer needed or entered in error.
CodeDisplayDefinition
activeActiveA current flag that should be displayed to a user. A system may use the category to determine which roles should view the flag.
inactiveInactiveThe flag does not need to be displayed any more.
entered-in-errorEntered in ErrorThe flag was added in error, and should no longer be displayed.

CodeSystem:EventStatus

Codes identifying the lifecycle stage of an event.
CodeDisplayDefinition
preparationPreparationThe core event has not started yet, but some staging activities have begun (e.g. surgical suite preparation). Preparation stages may be tracked for billing purposes.
in-progressIn ProgressThe event is currently occurring.
not-doneNot DoneThe event was terminated prior to any activity beyond preparation. I.e. The 'main' activity has not yet begun. The boundary between preparatory and the 'main' activity is context-specific.
on-holdOn HoldThe event has been temporarily stopped but is expected to resume in the future.
stoppedStoppedThe event was terminated prior to the full completion of the intended activity but after at least some of the 'main' activity (beyond preparation) has occurred.
completedCompletedThe event has now concluded.
entered-in-errorEntered in ErrorThis electronic record should never have existed, though it is possible that real-world decisions were based on it. (If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".).
unknownUnknownThe authoring/source system does not know which of the status values currently applies for this event. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which.

CodeSystem:ConditionVerificationStatus

The verification status to support or decline the clinical status of the condition or diagnosis.
CodeDisplayDefinition
unconfirmedUnconfirmedThere is not sufficient diagnostic and/or clinical evidence to treat this as a confirmed condition.
confirmedConfirmedThere is sufficient diagnostic and/or clinical evidence to treat this as a confirmed condition.
refutedRefutedThis condition has been ruled out by diagnostic and clinical evidence.
entered-in-errorEntered In ErrorThe statement was entered in error and is not valid.

CodeSystem:AdverseEventCategory

Overall categorization of the event, e.g. product related or situational.
CodeDisplayDefinition
product-problemProduct Problemundefined
product-qualityProduct Qualityundefined
product-use-errorProduct Use Errorundefined
medical-device-use-errorMedical Device Use Errorundefined
problem-different-manufacturerProblem with Different Manufacturer of Same Medicineundefined
unsafe-physical-environmentUnsafe Physical Environmentundefined

CodeSystem:FamilyHistoryAbsentReason

Codes describing the reason why a family member's history is not available.
CodeDisplayDefinition
subject-unknownSubject UnknownPatient does not know the subject, e.g. the biological parent of an adopted patient.
withheldInformation WithheldThe patient withheld or refused to share the information.
unable-to-obtainUnable To ObtainInformation cannot be obtained; e.g. unconscious patient.
deferredDeferredPatient does not have the information now, but can provide the information at a later date.

CodeSystem:CarePlanActivityStatus

Indicates where the activity is at in its overall life cycle.
CodeDisplayDefinition
not-startedNot StartedActivity is planned but no action has yet been taken.
scheduledScheduledAppointment or other booking has occurred but activity has not yet begun.
in-progressIn ProgressActivity has been started but is not yet complete.
on-holdOn HoldActivity was started but has temporarily ceased with an expectation of resumption at a future time.
completedCompletedThe activity has been completed (more or less) as planned.
cancelledCancelledThe planned activity has been withdrawn.
unknownUnknownThe current state of the activity is not known. Note: This concept is not to be used for "other".
entered-in-errorEntered In ErrorThe activity was entered in error and voided.

CodeSystem:GoalAchievementStatus

Describes the progression, or lack thereof, towards the goal against the target .
CodeDisplayDefinition
in-progressIn ProgressThe goal is being sought but has not yet been reached. (Also applies if goal was reached in the past but there has been regression and goal is being sought again).
achievedAchievedThe goal has been met.
not-achievedNot AchievedThe goal has not been met and there might or might not be progress towards target.

CodeSystem:AdverseEventSeverity

The severity of the adverse event itself, in direct relation to the subject.
CodeDisplayDefinition
mildMildundefined
moderateModerateundefined
severeSevereundefined

CodeSystem:AllergyIntoleranceType

Identification of the underlying physiological mechanism for a Reaction Risk.
CodeDisplayDefinition
allergyAllergyA propensity for hypersensitivity reaction(s) to a substance. These reactions are most typically type I hypersensitivity, plus other "allergy-like" reactions, including pseudoallergy.
intoleranceIntoleranceA propensity for adverse reactions to a substance that is not judged to be allergic or "allergy-like". These reactions are typically (but not necessarily) non-immune. They are to some degree idiosyncratic and/or individually specific (i.e. are not a reaction that is expected to occur with most or all patients given similar circumstances).

CodeSystem:AllergyIntoleranceSeverity

Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations.
CodeDisplayDefinition
mildMildCauses mild physiological effects.
moderateModerateCauses moderate physiological effects.
severeSevereCauses severe physiological effects.

CodeSystem:CommunicationNotDoneReason

Codes for the reason why a communication was not done.
CodeDisplayDefinition
unknownUnknownThe communication was not done due to an unknown reason.
system-errorSystem ErrorThe communication was not done due to a system error.
invalid-phone-numberInvalid Phone NumberThe communication was not done due to an invalid phone number.
recipient-unavailableRecipient UnavailableThe communication was not done due to the recipient being unavailable.
family-objectionFamily ObjectionThe communication was not done due to a family objection.
patient-objectionPatient ObjectionThe communication was not done due to a patient objection.

CodeSystem:GoalCategory

Example codes for grouping goals for filtering or presentation.
CodeDisplayDefinition
dietaryDietaryGoals related to the consumption of food and/or beverages.
safetySafetyGoals related to the personal protection of the subject.
behavioralBehavioralGoals related to the manner in which the subject acts.
nursingNursingGoals related to the practice of nursing or established by nurses.
physiotherapyPhysiotherapyGoals related to the mobility and motor capability of the subject.

CodeSystem:AllergyIntoleranceCategory

Category of an identified substance.
CodeDisplayDefinition
foodFoodAny substance consumed to provide nutritional support for the body.
medicationMedicationSubstances administered to achieve a physiological effect.
environmentEnvironmentAny substances that are encountered in the environment, including any substance not already classified as food, medication, or biologic.
biologicBiologicA preparation that is synthesized from living organisms or their products, especially a human or animal protein, such as a hormone or antitoxin, that is used as a diagnostic, preventive, or therapeutic agent. Examples of biologic medications include: vaccines; allergenic extracts, which are used for both diagnosis and treatment (for example, allergy shots); gene therapies; cellular therapies. There are other biologic products, such as tissues, that are not typically associated with allergies.

CodeSystem:AdverseEventActuality

Overall nature of the event, e.g. real or potential.
CodeDisplayDefinition
actualAdverse Eventundefined
potentialPotential Adverse Eventundefined

CodeSystem:GoalLifecycleStatus

Indicates whether the goal has been met and is still being targeted.
CodeDisplayDefinition
proposedProposedA goal is proposed for this patient.
plannedPlannedA goal is planned for this patient.
acceptedAcceptedA proposed goal was accepted or acknowledged.
cancelledCancelledThe goal has been abandoned.
entered-in-errorEntered In ErrorThe goal was entered in error and voided.
rejectedRejectedA proposed goal was rejected.

CodeSystem:AllergyIntoleranceVerificationStatusCodes

Preferred value set for AllergyIntolerance Verification Status.
CodeDisplayDefinition
unconfirmedUnconfirmedA low level of certainty about the propensity for a reaction to the identified substance.
confirmedConfirmedA high level of certainty about the propensity for a reaction to the identified substance, which may include clinical evidence by testing or rechallenge.
refutedRefutedA propensity for a reaction to the identified substance has been disputed or disproven with a sufficient level of clinical certainty to justify invalidating the assertion. This might or might not include testing or rechallenge.
entered-in-errorEntered In ErrorThe statement was entered in error and is not valid.

CodeSystem:CommunicationCategory

Codes for general categories of communications such as alerts, instruction, etc.
CodeDisplayDefinition
alertAlertThe communication conveys an alert.
notificationNotificationThe communication conveys a notification.
reminderReminderThe communication conveys a reminder.
instructionInstructionThe communication conveys instruction.

CodeSystem:FlagCategory

Example list of general categories for flagged issues. (Not complete or necessarily appropriate.)
CodeDisplayDefinition
dietDietFlags related to the subject's dietary needs.
drugDrugFlags related to the subject's medications.
labLabFlags related to performing laboratory tests and related processes (e.g. phlebotomy).
adminAdministrativeFlags related to administrative and financial processes.
contactSubject contactFlags related to coming into contact with the patient.
clinicalClinicalFlags related to the subject's clinical data.
behavioralBehavioralFlags related to behavior.
researchResearchFlags related to research.
advance-directiveAdvance DirectiveFlags related to subject's advance directives.
safetySafetyFlags related to safety precautions.

CodeSystem:LinkageType

Used to distinguish different roles a resource can play within a set of linked resources.
CodeDisplayDefinition
sourceSource of truthThe record represents the "source of truth" (from the perspective of this Linkage resource) for the underlying event/condition/etc.
alternateAlternate recordThe record represents the alternative view of the underlying event/condition/etc. The record may still be actively maintained, even though it is not considered to be the source of truth.
historicalHistorical/obsolete recordThe record represents an obsolete record of the underlying event/condition/etc. It is not expected to be actively maintained.

CodeSystem:ConditionCategoryCodes

Preferred value set for Condition Categories.
CodeDisplayDefinition
problem-list-itemProblem List ItemAn item on a problem list which can be managed over time and can be expressed by a practitioner (e.g. physician, nurse), patient, or related person.
encounter-diagnosisEncounter DiagnosisA point in time diagnosis (e.g. from a physician or nurse) in context of an encounter.

CodeSystem:AllergyIntoleranceCriticality

Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance.
CodeDisplayDefinition
lowLow RiskWorst case result of a future exposure is not assessed to be life-threatening or having high potential for organ system failure.
highHigh RiskWorst case result of a future exposure is assessed to be life-threatening or having high potential for organ system failure.
unable-to-assessUnable to Assess RiskUnable to assess the worst case result of a future exposure.

CodeSystem:AdverseEventCausalityMethod

TODO.
CodeDisplayDefinition
ProbabilityScaleProbability Scaleundefined
BayesianBayesianundefined
ChecklistChecklistundefined

CodeSystem:AdverseEventOutcome

TODO (and should this be required?).
CodeDisplayDefinition
resolvedResolvedundefined
recoveringRecoveringundefined
ongoingOngoingundefined
resolvedWithSequelaeResolved with Sequelaeundefined
fatalFatalundefined
unknownUnknownundefined

CodeSystem:AllergyIntoleranceClinicalStatusCodes

Preferred value set for AllergyIntolerance Clinical Status.
CodeDisplayDefinition
activeActiveThe subject is currently experiencing or at risk of a reaction to the identified substance.
inactiveInactiveThe subject is no longer at risk of a reaction to the identified substance.

CodeSystem:CommunicationTopic

Codes describing the purpose or content of the communication.
CodeDisplayDefinition
prescription-refill-requestPrescription Refill RequestThe purpose of the communication is a prescription refill request.
progress-updateProgress UpdateThe purpose of the communication is a progress update.
report-labsReport LabsThe purpose of the communication is to report labs.
appointment-reminderAppointment ReminderThe purpose of the communication is an appointment reminder.
phone-consultPhone ConsultThe purpose of the communication is a phone consult.
summary-reportSummary ReportThe purpose of the communication is a summary report.

CodeSystem:AdverseEventSeriousness

Overall seriousness of this event for the patient.
CodeDisplayDefinition
Non-seriousNon-seriousNon-serious.
SeriousSeriousSerious.

CodeSystem:ProcedureDeviceActionCodes

Example codes indicating the change that happened to the device during the procedure. Note that these are in no way complete and might not even be appropriate for some uses.
CodeDisplayDefinition
implantedImplantedThe device was implanted in the patient during the procedure.
explantedExplantedThe device was explanted from the patient during the procedure.
manipulatedManipulatedThe device remains in that patient, but its location, settings, or functionality was changed.

CodeSystem:GoalPriority

Indicates the level of importance associated with reaching or sustaining a goal.
CodeDisplayDefinition
high-priorityHigh PriorityIndicates that the goal is of considerable importance and should be a primary focus of care delivery.
medium-priorityMedium PriorityIndicates that the goal has a reasonable degree of importance and that concrete action should be taken towards the goal. Attainment is not as critical as high-priority goals.
low-priorityLow PriorityThe goal is desirable but is not sufficiently important to devote significant resources to. Achievement of the goal may be sought when incidental to achieving other goals.

CodeSystem:ConditionClinicalStatusCodes

Preferred value set for Condition Clinical Status.
CodeDisplayDefinition
activeActiveThe subject is currently experiencing the symptoms of the condition or there is evidence of the condition.
inactiveInactiveThe subject is no longer experiencing the symptoms of the condition or there is no longer evidence of the condition.

ValueSet: ProcedureOutcomeCodes(SNOMEDCT)

Procedure Outcome code: A selection of relevant SNOMED CT codes.

ValueSet: ConditionStageType

Example value set for the type of stages of cancer and other conditions

ValueSet: AllergyIntoleranceCertainty

Statement about the degree of clinical certainty that a specific substance was the cause of the manifestation in a reaction event.

ValueSet: GoalRelationshipType

Types of relationships between two goals.

ValueSet: ConditionState

Enumeration indicating whether the condition is currently active, inactive, or has been resolved.

ValueSet: CommunicationCategory

Codes for general categories of communications such as alerts, instruction, etc.

ValueSet: CareTeamStatus

Indicates the status of the care team.

ValueSet: CommunicationNotDoneReason

Codes for the reason why a communication was not done.

ValueSet: AllergyIntoleranceType

Identification of the underlying physiological mechanism for a Reaction Risk.

ValueSet: CarePlanActivityKind

Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.

ValueSet: AdverseEventActuality

Overall nature of the event, e.g. real or potential.

ValueSet: ProcedureFollowUpCodes(SNOMEDCT)

Procedure follow up codes: a selection of SNOMED CT codes relevant to procedure follow up.

ValueSet: Condition/DiagnosisSeverity

Preferred value set for Condition/Diagnosis severity grading

ValueSet: Condition/Problem/DiagnosisCodes

Example value set for Condition/Problem/Diagnosis codes

ValueSet: CarePlanCategory

Example codes indicating the category a care plan falls within. Note that these are in no way complete and might not even be appropriate for some uses.

ValueSet: ConditionOutcomeCodes

Example value set for Condition Outcomes

ValueSet: RequestPriority

The clinical priority of a diagnostic order.

ValueSet: AllergyIntoleranceClinicalStatusCodes

Preferred value set for AllergyIntolerance Clinical Status.

ValueSet: InvestigationType

Example value set for investigation type

ValueSet: FlagStatus

Indicates whether this flag is active and needs to be displayed to a user, or whether it is no longer needed or entered in error.

ValueSet: ParentRelationshipCodes

The value set includes the v3 RoleCode PRN (parent), TWIN (twin) and all of their specializations. It covers the relationships needed to establish genetic pedigree relationships between family members.

ValueSet: GoalAcceptanceStatus

Codes indicating whether the goal has been accepted by a stakeholder.

ValueSet: CareTeamCategory

Indicates the type of care team.

ValueSet: AllergyIntoleranceCategory

Category of an identified substance.

ValueSet: ProcedureReasonCodes

This examples value set defines the set of codes that can be used to indicate a reasons for a procedure.

ValueSet: ManifestationAndSymptomCodes

Example value set for Manifestation and Symptom codes.

ValueSet: GoalLifecycleStatus

Indicates whether the goal has been met and is still being targeted.

ValueSet: SiblingRelationshipCodes

The value set includes the v3 RoleCode SIB (sibling) and all of its specializations. It covers the relationships needed to establish genetic pedigree relationships between family members.

ValueSet: ClinicalImpressionPrognosis

Example value set clinical impression prognosis

ValueSet: ProcedureCodes(SNOMEDCT)

Procedure Code: All SNOMED CT procedure codes.

ValueSet: GoalStatusReason

Example codes indicating the reason for a current status. Note that these are in no way complete and might not even be appropriate for some uses.

ValueSet: ConditionClinicalStatusCodes

Preferred value set for Condition Clinical Status.

ValueSet: AdverseEventOutcome

TODO (and should this be required?).

ValueSet: ConditionStage

Example value set for stages of cancer and other conditions

ValueSet: SNOMEDCTClinicalFindings

This value set includes all SNOMED CT Clinical Findings.

ValueSet: ConditionVerificationStatus

The verification status to support or decline the clinical status of the condition or diagnosis.

ValueSet: AdverseEventSeriousness

Overall seriousness of this event for the patient.

ValueSet: FlagPriorityCodes

This value set is provided as an exemplar. The value set is driven by IHE Table B.8-4: Abnormal Flags, Alert Priority.

ValueSet: FlagCode

Example list of detail codes for flagged issues. (Not complete or necessarily appropriate.)

ValueSet: ConditionPredecessorCodes

Example value set for Condition Predecessor codes

ValueSet: AllergyIntoleranceVerificationStatusCodes

Preferred value set for AllergyIntolerance Verification Status.

ValueSet: ProcedureDeviceActionCodes

Example codes indicating the change that happened to the device during the procedure. Note that these are in no way complete and might not even be appropriate for some uses.

ValueSet: AdverseEventCausalityMethod

TODO.

ValueSet: AdverseEventSeverity

The severity of the adverse event itself, in direct relation to the subject.

ValueSet: ProcedureCategoryCodes(SNOMEDCT)

Procedure Category code: A selection of relevant SNOMED CT codes.

ValueSet: GoalAchievementStatus

Describes the progression, or lack thereof, towards the goal against the target .

ValueSet: FamilyHistoryAbsentReason

Codes describing the reason why a family member's history is not available.

ValueSet: ProcedurePerformerRoleCodes

This examples value set defines the set of codes that can be used to indicate a role of procedure performer.

ValueSet: ProcedureNotPerformedReason(SNOMED-CT)

Situation codes describing the reason that a procedure, which might otherwise be expected, was not performed, or a procedure that was started and was not completed. Consists of SNOMED CT codes, children of procedure contraindicated (183932001), procedure discontinued (416406003), procedure not done (416237000), procedure not indicated (428119001), procedure not offered (416064006), procedure not wanted (416432009), procedure refused (183944003), and procedure stopped (394908001).

ValueSet: AdverseEventCausalityAssessment

TODO.

ValueSet: AllergyIntoleranceCriticality

Estimate of the potential clinical harm, or seriousness, of a reaction to an identified substance.

ValueSet: AllergyIntoleranceSubstanceExposureRisk

The risk of an adverse reaction (allergy or intolerance) for this patient upon exposure to the substance (including pharmaceutical products).

ValueSet: CarePlanActivityOutcome

Example codes indicating the outcome of a care plan activity. Note that these are in no way complete and might not even be appropriate for some uses.

ValueSet: FlagCategory

Example list of general categories for flagged issues. (Not complete or necessarily appropriate.)

ValueSet: ClinicalImpressionStatus

Codes identifying the lifecycle stage of a clinical impression

ValueSet: AllergyIntoleranceSeverity

Clinical assessment of the severity of a reaction event as a whole, potentially considering multiple different manifestations.

ValueSet: CarePlanActivityStatus

Indicates where the activity is at in its overall life cycle.

ValueSet: LinkageType

Used to distinguish different roles a resource can play within a set of linked resources.

ValueSet: GoalStartEvent

Identifies types of events that might trigger the start of a goal.

ValueSet: AdverseEventCategory

Overall categorization of the event, e.g. product related or situational.

ValueSet: ConditionCauseCodes

Example value set for Cause of Condition codes

ValueSet: FamilyHistoryStatus

A code that identifies the status of the family history record.

ValueSet: ConditionCategoryCodes

Preferred value set for Condition Categories.

ValueSet: GoalCategory

Example codes for grouping goals for filtering or presentation.

ValueSet: CarePlanIntent

Codes indicating the degree of authority/intentionality associated with a care plan.

ValueSet: ParticipantRoles

Roles of Participants that may be included in a CarePlan.Participants, or in an EpisodeOfCare.team. Defined as: Is a Person, Healthcare professional (occupation) or Healthcare related organization (qualifier value).

ValueSet: AllergyIntoleranceSubstance/Product,ConditionAndNegationCodes

This value set includes concept codes for specific substances/pharmaceutical products, allergy or intolerance conditions, and negation/exclusion codes to specify the absence of specific types of allergies or intolerances.

ValueSet: ProcedureProgressStatusCodes

This value set is provided as an example. The value set to instantiate this attribute should be drawn from a robust terminology code system that consists of or contains concepts to support the procedure performance process.

ValueSet: GoalPriority

Indicates the level of importance associated with reaching or sustaining a goal.

ValueSet: CommunicationTopic

Codes describing the purpose or content of the communication.