Patient Administration Work Group | Maturity Level: N | Normative (from v4.0.0) | Security Category: Patient | Compartments: Patient, Practitioner, RelatedPerson |
Detailed Descriptions for the elements in the Patient resource.
| Patient | |||||||||
| Element Id | Patient | ||||||||
| Definition | 接受医疗健康服务个人的人口学信息或动物的管理信息。 | ||||||||
| Cardinality | 0..* | ||||||||
| Type | DomainResource | ||||||||
| Requirements | 医疗过程是以患者为中心的。 | ||||||||
| Alternate Names | SubjectOfCare Client Resident | ||||||||
| Patient.identifier | |||||||||
| Element Id | Patient.identifier | ||||||||
| Definition | An identifier for this patient. | ||||||||
| Note | This is a business identifier, not a resource identifier (see discussion) | ||||||||
| Cardinality | 0..* | ||||||||
| Type | Identifier | ||||||||
| Requirements | Patients are almost always assigned specific numerical identifiers. | ||||||||
| Summary | true | ||||||||
| Patient.active | |||||||||
| Element Id | Patient.active | ||||||||
| Definition | 此患者记录是否正在使用中。许多系统使用此属性将患者标记为非当前患者,例如根据组织的业务规则在一段时间内未就诊的患者。 它通常用于筛选正在使用患者记录,排除不活动的患者。 死亡的病人也可能被标记为不活动,但在死亡后的一段时间内病历可能还在使用,可以认为是活动的。 | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | boolean | ||||||||
| Is Modifier | true (原因: 此元素值为fasle时,意味着此记录应被视为无效) | ||||||||
| Meaning if Missing | 如果没有为active元素提供值,则默认假定此资源是活动的 | ||||||||
| Requirements | 需要能够将错误创建的记录标记为不使用(False)。 | ||||||||
| Summary | true | ||||||||
| Comments | 如果某个患者记录A处于非活动状态并被链接到另一个处于活动状态的患者记录B,则后来对患者记录的更新应在B上进行。 | ||||||||
| Patient.name | |||||||||
| Element Id | Patient.name | ||||||||
| Definition | 与患者相关的名字 | ||||||||
| Cardinality | 0..* | ||||||||
| Type | HumanName | ||||||||
| Requirements | 需要能够通过不同的姓名定位可能的患者。例如包括户口姓名、曾用名、笔名、学名、乳名等 | ||||||||
| Summary | true | ||||||||
| Comments | 患者可能在不同时期有多个不同用途的名字。对动物名字仍然是一个HumanName数据类型,因为它是由人类指定和使用的,并且具有相同的模式。 | ||||||||
| Patient.telecom | |||||||||
| Element Id | Patient.telecom | ||||||||
| Definition | A contact detail (e.g. a telephone number or an email address) by which the individual may be contacted. | ||||||||
| Cardinality | 0..* | ||||||||
| Type | ContactPoint | ||||||||
| Requirements | People have (primary) ways to contact them in some way such as phone, email. | ||||||||
| Summary | true | ||||||||
| Comments | A Patient may have multiple ways to be contacted with different uses or applicable periods. May need to have options for contacting the person urgently and also to help with identification. The address might not go directly to the individual, but may reach another party that is able to proxy for the patient (i.e. home phone, or pet owner's phone). | ||||||||
| Patient.gender | |||||||||
| Element Id | Patient.gender | ||||||||
| Definition | Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes. | ||||||||
| Cardinality | 0..1 | ||||||||
| Terminology Binding | AdministrativeGender (Required) | ||||||||
| Type | code | ||||||||
| Requirements | Needed for identification of the individual, in combination with (at least) name and birth date. | ||||||||
| Summary | true | ||||||||
| Comments | The gender might not match the biological sex as determined by genetics or the individual's preferred identification. Note that for both humans and particularly animals, there are other legitimate possibilities than male and female, though the vast majority of systems and contexts only support male and female. Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific sex or gender aspect of interest (anatomical, chromosomal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. Where such defaulting occurs, rule enforcement should allow for the variation between administrative and biological, chromosomal and other gender aspects. For example, an alert about a hysterectomy on a male should be handled as a warning or overridable error, not a "hard" error. See the Patient Gender and Sex section for additional information about communicating patient gender and sex. | ||||||||
| Patient.birthDate | |||||||||
| Element Id | Patient.birthDate | ||||||||
| Definition | The date of birth for the individual. | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | date | ||||||||
| Requirements | Age of the individual drives many clinical processes. | ||||||||
| Summary | true | ||||||||
| Comments | At least an estimated year should be provided as a guess if the real DOB is unknown There is a standard extension "patient-birthTime" available that should be used where Time is required (such as in maternity/infant care systems). | ||||||||
| LOINC Code | 21112-8 | ||||||||
| Patient.deceased[x] | |||||||||
| Element Id | Patient.deceased[x] | ||||||||
| Definition | Indicates if the individual is deceased or not. | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | boolean|dateTime | ||||||||
| [x] Note | See Choice of Data Types for further information about how to use [x] | ||||||||
| Is Modifier | true (Reason: This element is labeled as a modifier because once a patient is marked as deceased, the actions that are appropriate to perform on the patient may be significantly different.) | ||||||||
| 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. | ||||||||
| Summary | true | ||||||||
| Comments | If there's no value in the instance, it means there is no statement on whether or not the individual is deceased. Most systems will interpret the absence of a value as a sign of the person being alive. | ||||||||
| Patient.address | |||||||||
| Element Id | Patient.address | ||||||||
| Definition | An address for the individual. | ||||||||
| Cardinality | 0..* | ||||||||
| Type | Address | ||||||||
| Requirements | May need to keep track of patient addresses for contacting, billing or reporting requirements and also to help with identification. | ||||||||
| Summary | true | ||||||||
| Comments | Patient may have multiple addresses with different uses or applicable periods. | ||||||||
| Patient.maritalStatus | |||||||||
| Element Id | Patient.maritalStatus | ||||||||
| Definition | This field contains a patient's most recent marital (civil) status. | ||||||||
| Cardinality | 0..1 | ||||||||
| Terminology Binding | MaritalStatus (Extensible) | ||||||||
| Type | CodeableConcept | ||||||||
| Requirements | Most, if not all systems capture it. | ||||||||
| Patient.multipleBirth[x] | |||||||||
| Element Id | Patient.multipleBirth[x] | ||||||||
| Definition | Indicates whether the patient is part of a multiple (boolean) or indicates the actual birth order (integer). | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | boolean|integer | ||||||||
| [x] Note | See Choice of Data Types for further information about how to use [x] | ||||||||
| Requirements | For disambiguation of multiple-birth children, especially relevant where the care provider doesn't meet the patient, such as labs. | ||||||||
| Comments | Where the valueInteger is provided, the number is the birth number in the sequence. E.g. The middle birth in triplets would be valueInteger=2 and the third born would have valueInteger=3 If a boolean value was provided for this triplets example, then all 3 patient records would have valueBoolean=true (the ordering is not indicated). | ||||||||
| Patient.photo | |||||||||
| Element Id | Patient.photo | ||||||||
| Definition | Image of the patient. | ||||||||
| Cardinality | 0..* | ||||||||
| Type | Attachment | ||||||||
| Requirements | Many EHR systems have the capability to capture an image of the patient. Fits with newer social media usage too. | ||||||||
| Comments | Guidelines:
| ||||||||
| Patient.contact | |||||||||
| Element Id | Patient.contact | ||||||||
| Definition | A contact party (e.g. guardian, partner, friend) for the patient. | ||||||||
| Cardinality | 0..* | ||||||||
| Requirements | Need to track people you can contact about the patient. | ||||||||
| Comments | Contact covers all kinds of contact parties: family members, business contacts, guardians, caregivers. Not applicable to register pedigree and family ties beyond use of having contact. | ||||||||
| Invariants |
| ||||||||
| Patient.contact.relationship | |||||||||
| Element Id | Patient.contact.relationship | ||||||||
| Definition | The nature of the relationship between the patient and the contact person. | ||||||||
| Cardinality | 0..* | ||||||||
| Terminology Binding | Patient Contact Relationship (Extensible) | ||||||||
| Type | CodeableConcept | ||||||||
| Requirements | Used to determine which contact person is the most relevant to approach, depending on circumstances. | ||||||||
| Patient.contact.name | |||||||||
| Element Id | Patient.contact.name | ||||||||
| Definition | A name associated with the contact person. | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | HumanName | ||||||||
| Requirements | Contact persons need to be identified by name, but it is uncommon to need details about multiple other names for that contact person. | ||||||||
| Patient.contact.telecom | |||||||||
| Element Id | Patient.contact.telecom | ||||||||
| Definition | A contact detail for the person, e.g. a telephone number or an email address. | ||||||||
| Cardinality | 0..* | ||||||||
| Type | ContactPoint | ||||||||
| Requirements | People have (primary) ways to contact them in some way such as phone, email. | ||||||||
| Comments | Contact may have multiple ways to be contacted with different uses or applicable periods. May need to have options for contacting the person urgently, and also to help with identification. | ||||||||
| Patient.contact.address | |||||||||
| Element Id | Patient.contact.address | ||||||||
| Definition | Address for the contact person. | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | Address | ||||||||
| Requirements | Need to keep track where the contact person can be contacted per postal mail or visited. | ||||||||
| Patient.contact.gender | |||||||||
| Element Id | Patient.contact.gender | ||||||||
| Definition | Administrative Gender - the gender that the contact person is considered to have for administration and record keeping purposes. | ||||||||
| Cardinality | 0..1 | ||||||||
| Terminology Binding | AdministrativeGender (Required) | ||||||||
| Type | code | ||||||||
| Requirements | Needed to address the person correctly. | ||||||||
| Patient.contact.organization | |||||||||
| Element Id | Patient.contact.organization | ||||||||
| Definition | Organization on behalf of which the contact is acting or for which the contact is working. | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | Reference(Organization) | ||||||||
| Requirements | For guardians or business related contacts, the organization is relevant. | ||||||||
| Invariants |
| ||||||||
| Patient.contact.period | |||||||||
| Element Id | Patient.contact.period | ||||||||
| Definition | The period during which this contact person or organization is valid to be contacted relating to this patient. | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | Period | ||||||||
| Patient.communication | |||||||||
| Element Id | Patient.communication | ||||||||
| Definition | A language which may be used to communicate with the patient about his or her health. | ||||||||
| Cardinality | 0..* | ||||||||
| Requirements | If a patient does not speak the local language, interpreters may be required, so languages spoken and proficiency are important things to keep track of both for patient and other persons of interest. | ||||||||
| Comments | If no language is specified, this implies that the default local language is spoken. If you need to convey proficiency for multiple modes, then you need multiple Patient.Communication associations. For animals, language is not a relevant field, and should be absent from the instance. If the Patient does not speak the default local language, then the Interpreter Required Standard can be used to explicitly declare that an interpreter is required. | ||||||||
| Patient.communication.language | |||||||||
| Element Id | Patient.communication.language | ||||||||
| 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. | ||||||||
| Cardinality | 1..1 | ||||||||
| Terminology Binding | Common Languages (Preferred but limited to All Languages) | ||||||||
| Type | CodeableConcept | ||||||||
| Requirements | Most systems in multilingual countries will want to convey language. Not all systems actually need the regional dialect. | ||||||||
| Comments | The structure aa-BB with this exact casing is one the most widely used notations for locale. However not all systems actually code this but instead have it as free text. Hence CodeableConcept instead of code as the data type. | ||||||||
| Patient.communication.preferred | |||||||||
| Element Id | Patient.communication.preferred | ||||||||
| Definition | Indicates whether or not the patient prefers this language (over other languages he masters up a certain level). | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | boolean | ||||||||
| 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. | ||||||||
| Comments | This language is specifically identified for communicating healthcare information. | ||||||||
| Patient.generalPractitioner | |||||||||
| Element Id | Patient.generalPractitioner | ||||||||
| Definition | Patient's nominated care provider. | ||||||||
| Cardinality | 0..* | ||||||||
| Type | Reference(Organization | Practitioner | PractitionerRole) | ||||||||
| Alternate Names | careProvider | ||||||||
| Comments | This may be the primary care provider (in a GP context), or it may be a patient nominated care manager in a community/disability setting, or even organization that will provide people to perform the care provider roles. It is not to be used to record Care Teams, these should be in a CareTeam resource that may be linked to the CarePlan or EpisodeOfCare resources. Multiple GPs may be recorded against the patient for various reasons, such as a student that has his home GP listed along with the GP at university during the school semesters, or a "fly-in/fly-out" worker that has the onsite GP also included with his home GP to remain aware of medical issues. Jurisdictions may decide that they can profile this down to 1 if desired, or 1 per type. | ||||||||
| Patient.managingOrganization | |||||||||
| Element Id | Patient.managingOrganization | ||||||||
| Definition | Organization that is the custodian of the patient record. | ||||||||
| Cardinality | 0..1 | ||||||||
| Type | Reference(Organization) | ||||||||
| Requirements | Need to know who recognizes this patient record, manages and updates it. | ||||||||
| Summary | true | ||||||||
| Comments | There is only one managing organization for a specific patient record. Other organizations will have their own Patient record, and may use the Link property to join the records together (or a Person resource which can include confidence ratings for the association). | ||||||||
| Patient.link | |||||||||
| Element Id | Patient.link | ||||||||
| Definition | Link to another patient resource that concerns the same actual patient. | ||||||||
| Cardinality | 0..* | ||||||||
| Is Modifier | true (Reason: This element is labeled as a modifier because it might not be the main Patient resource, and the referenced patient should be used instead of this Patient record. This is when the link.type value is 'replaced-by') | ||||||||
| Requirements | There are multiple use cases:
| ||||||||
| Summary | true | ||||||||
| Comments | There is no assumption that linked patient records have mutual links. | ||||||||
| Patient.link.other | |||||||||
| Element Id | Patient.link.other | ||||||||
| Definition | The other patient resource that the link refers to. | ||||||||
| Cardinality | 1..1 | ||||||||
| Type | Reference(Patient | RelatedPerson) | ||||||||
| Hierarchy | This reference may point back to the same instance (including transitively) | ||||||||
| Summary | true | ||||||||
| Comments | Referencing a RelatedPerson here removes the need to use a Person record to associate a Patient and RelatedPerson as the same individual. | ||||||||
| Patient.link.type | |||||||||
| Element Id | Patient.link.type | ||||||||
| Definition | The type of link between this patient resource and another patient resource. | ||||||||
| Cardinality | 1..1 | ||||||||
| Terminology Binding | LinkType (Required) | ||||||||
| Type | code | ||||||||
| Summary | true | ||||||||