ActClass |
Lvl |
Type, Domain name and/or Mnemonic code |
Concept ID |
Mnemonic |
Print Name |
Definition/Description |
1
|
S: ActRootClass (ACT)
|
13856 |
ACT |
Act |
An action of interest that has happened, can happen, is happening, is intended to happen, or is requested/demanded to happen.
An act is an intentional action in the business domain of HL7. Healthcare (and any profession or business) is constituted
of intentional actions. An Act instance is a record of such an intentional action.
Any intentional action can exist in different "moods". Moods describe activities as they progress in the business cycle,
from defined, through planned and ordered to complete.
Any instance of an Act assumes one and only one mood and will not change its mood along its life cycle. The moods - definition,
intent, order, event - seem to specify a life cycle of an activity. However, the participants in the activity in these different
moods are different, as is the data. Therefore, the mood of an Act instance is static. The progression actualization (i.e.,
the progression from defined, through planned and ordered, to being performed) is called the "business cycle" to distinguish
it from the "life cycle" of a single act instance. Related Act instances that form such a "business cycle" are linked through
the Act_relationship class.
Examples for acts in health care are: a clinical test, an assessment of health condition (such as problems and diagnoses),
the setting of healthcare goals, the performance of treatment services (such as medication, surgery, physical and psychological
therapy), assisting, monitoring or attending, training and education services to patients and their next of kin, and notary
services (such as advanced directives or living will).
Acts have participants, which can be actors or targets. Examples of actors are nurses, doctors, family members, notary publics,
and service organizations -- every person or organization that is capable of independent decisions and can thus is responsible
(and liable) for the actions performed.
Target participants in an act may include the patient, the patient's spouse, family, or community, a specimen drawn from the
patient or from any object of interest. As patients do play active roles in their own healthcare, the patient can be both
an active participant and a target participant at the same time (self-administered or reflexive services.)
An act can have multiple active participants and multiple target participants, their specific role being distinguished in
the "type_cd" of the respective instance of the Participation class. In particular, an act involving coordination of care
may involve two or more active participants -- playing different roles -- who interact on behalf of a patient, family, or
aggregate in the role of target participant. For example, a nurse (active participant) calls Meals on Wheels (active participant)
on behalf of the patient (target participant).
An act includes the "results", "answers" or informational "procedure products" gained during the act. In this model, "results"
do not exist without an act, and every clinical result, including those results gained accidentally, is gleaned via an act.
In other moods, such as "definition " or "intent", the results are the possible results, the expected or aimed-for results,
or the tested-for results.
|
2
|
S: ActConfirmationClass (CONF)
|
13999 |
CONF |
Confirmation |
A notification used to indicate whether a request or inquiry has been confirmed. |
3
|
L: (AUTH)
|
14001 |
AUTH |
Authorization |
A notification used to indicate whether an intent to perform a billable act has been approved for coverage under the terms
of an insurance plan or policy.
|
3
|
L: (ELIG)
|
14000 |
ELIG |
Eligibility |
A notification used to indicate whether a beneficiary is eligible for coverage under the terms of an insurance plan or policy. |
2
|
S: ActContractClass (CNTRCT)
|
14002 |
CNTRCT |
Contract |
An agreement of obligation between two or more parties that is subject to contractual law and enforcement. |
3
|
S: ActFinancialContractClass (FCNTRCT)
|
14003 |
FCNTRCT |
Financial contract |
A contract whose value is measured in monetary terms. |
4
|
L: (COV)
|
14004 |
COV |
Coverage |
A health care insurance policy or plan that is contractually binding between two or more parties. |
2
|
A: ActDocumentStructureClass |
13945 |
|
|
A structure is a container within a document. Structures have captions which can be coded. Structures can nest, and structures
can contain entries.
|
3
|
S: ActClinicalDocument (DOCCLIN)
|
13948 |
DOCCLIN |
Clinical document |
A clinical document is a documentation of clinical observations and services, with the following characteristics: (1) Persistence
- A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements;
(2) Stewardship - A clinical document is maintained by a person or organization entrusted with its care; (3) Potential for
authentication - A clinical document is an assemblage of information that is intended to be legally authenticated; (4) Wholeness
- Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full
context of the document; (5) Human readability - A clinical document is human readable."
|
4
|
L: (CDALVLONE)
|
14795 |
CDALVLONE |
CDA Level One clinical document |
A clinical document that conforms to Level One of the HL7 Clinical Document Architecture (CDA) |
3
|
S: DocumentList (DOCLIST)
|
14787 |
DOCLIST |
Document list |
A list of items |
4
|
A: ListType |
10978 |
|
|
Specifies whether a list is "ordered" or "unordered". Use an ordered list when the ordering of list items is meaningful. |
5
|
L: (ordered)
|
10979 |
ordered |
ordered |
|
5
|
L: (unordered)
|
10980 |
unordered |
unordered |
|
3
|
A: DocumentTableStructure |
14773 |
|
|
A table structure is either a column structure, a row structure, or a table cell. |
4
|
A: DocumentTableCell |
14774 |
|
|
A cell in a table. |
5
|
L: (TBLDATA)
|
14776 |
TBLDATA |
Document table data cell |
A data cell in a table |
5
|
L: (TBLHDR)
|
14775 |
TBLHDR |
Document table header cell |
A header cell in a table |
4
|
A: DocumentTableColumnStructure |
14781 |
|
|
A table column or column group. |
5
|
L: (TBLCOL)
|
14782 |
TBLCOL |
Document table column |
A column in a table |
5
|
L: (TBLCOLGP)
|
14783 |
TBLCOLGP |
Document table column group |
A defined group of columns in a table |
4
|
A: DocumentTableRowStructure |
14777 |
|
|
A table row |
5
|
A: DocumentTableRowGroup |
14779 |
|
|
A defined group of rows in a table |
6
|
A: TableRowGroupType |
11008 |
|
|
Segment types specify table header, table footer, or table body, as defined within the XHTML 4.0 Table Model |
7
|
L: (tbody)
|
11009 |
tbody |
tbody |
Table body, as defined within the XHTML 4.0 Table Model |
7
|
L: (tfoot)
|
11010 |
tfoot |
tfoot |
Table footer, as defined within the XHTML 4.0 Table Model |
7
|
L: (thead)
|
11011 |
thead |
thead |
Table header, as defined within the XHTML 4.0 Table Model |
5
|
L: (TBLROW)
|
14778 |
TBLROW |
Document table row |
A row in a table |
3
|
L: (DOCBODY)
|
13947 |
DOCBODY |
Document body |
Represents the body of a document on the Clinical Document Architecture standards. |
3
|
L: (DOCCNTNT)
|
14785 |
DOCCNTNT |
Document content |
A non-semantic wrapper for plain text in a clinical document |
3
|
L: (DOCLSTITM)
|
14789 |
DOCLSTITM |
Document list item |
An item in a list |
3
|
L: (DOCPARA)
|
14786 |
DOCPARA |
Document paragraph |
A paragraph in a clinical document |
3
|
L: (DOCSECT)
|
13946 |
DOCSECT |
Document section |
Represents a section in a document on the Clinical Document Architecture standards. |
3
|
L: (DOCTBL)
|
14784 |
DOCTBL |
Document table |
A container consisting of multiple cells arranged in rows and columns. |
2
|
S: ActFinancialClass (FIN)
|
11544 |
FIN |
Financial Act |
An act utilized primarily for administrative (versus clinical) purposes. |
3
|
S: ActInvoiceElementClass (INVE)
|
13992 |
INVE |
Invoice element |
Represents concepts related to invoice processing in health care |
4
|
L: (INFINVE)
|
14022 |
INFINVE |
Informational invoice element |
A piece of supporting information or detail that does not alter the financial total of an invoice. |
3
|
L: (ACCT)
|
13991 |
ACCT |
Account |
A financial account established to track the net result of financial acts. |
3
|
L: (INS)
|
11548 |
INS |
Healthcare benefit coverage |
This type covers both the healthcare benefit product policy, and the coverage item, until such time as the mapping is complete. |
3
|
L: (XACT)
|
11545 |
XACT |
Financial transaction |
A sub-class of Act representing any transaction between two accounts whose value is measured in monetary terms.
In the "intent" mood, communicates a request for a transaction to be initiated, or communicates a transfer of value between
two accounts.
In the "event" mood, communicates the posting of a transaction to an account.
|
2
|
S: ActIncidentClass (INC)
|
13989 |
INC |
Incident |
An event that occurred outside of the control of one or more of the parties involved. Includes the concept of an accident. |
3
|
L: (JOBINC)
|
13990 |
JOBINC |
Job related incident |
An incident that occurred at the individual's place of employment. |
2
|
S: ActObservationClass (OBS)
|
11529 |
OBS |
Observation |
Observations are actions performed in order to determine an answer or result value. Observation result values (Observation.value)
include specific information about the observed object. The type and constraints of result values depend on the kind of action
performed.
Clinical documents commonly have 'Subjective' and 'Objective' findings, both of which are kinds of Observations. In addition,
clinical documents commonly contain 'Assessments', which are also kinds of Observations. Thus, the establishment of a diagnosis
is an Observation.
|
3
|
A: ActLabObsClass |
13949 |
|
|
Provides an abstract root class for laboratory observations |
4
|
L: (ARTBLD)
|
14038 |
ARTBLD |
Artificial Blood |
Describes the artificial blood identifier that is associated with the specimen. |
4
|
L: (CNTM)
|
14037 |
CNTM |
Contaminants |
Describes the specimen contaminant identifier that is associated with the specimen |
4
|
L: (DILUTION)
|
13950 |
DILUTION |
Dilution |
An observation that reports the dilution of a sample. |
4
|
L: (ENVFCTS)
|
14039 |
ENVFCTS |
Environmental Factors |
Describes other environmental factors that are associated with the specimen, e.g., atmospheric exposure |
4
|
L: (INTFRIDX)
|
14036 |
INTFRIDX |
Interference Index |
A class of observations that relate to factors that may potentially cause interference with the observation |
4
|
L: (TEMP)
|
14035 |
TEMP |
Temperature |
The specimen temperature in degrees Celsius [oC] at the time of the observation |
4
|
L: (VOLUME)
|
13951 |
VOLUME |
Volume |
An observation that reports the volume of a sample. |
3
|
S: ActPublicHealthCaseClass (CASE)
|
11530 |
CASE |
Public Health Case |
A public health case is an Observation representing a condition or event that has a specific significance for public health.
Typically it involves an instance or instances of a reportable infectious disease or other condition. The public health case
can include a health-related event concerning a single individual or it may refer to multiple health-related events that are
occurrences of the same disease or condition of interest to public health. An outbreak involving multiple individuals may
be considered as a type of public health case. A public health case definition (Act.mood_cd = "definition") includes the description
of the clinical, laboratory, and epidemiologic indicators associated with a disease or condition of interest to public health.
There are case definitions for conditions that are reportable, as well as for those that are not. There are also case definitions
for outbreaks. A public health case definition is a construct used by public health for the purpose of counting cases, and
should not be used as clinical indications for treatment. Examples include AIDS, toxic-shock syndrome, and salmonellosis and
their associated indicators that are used to define a case.
|
4
|
L: (OUTB)
|
11531 |
OUTB |
Outbreak |
An outbreak represents a series of public health cases. The date on which an outbreak starts is the earliest date of onset
among the cases assigned to the outbreak, and its ending date is the last date of onset among the cases assigned to the outbreak.
|
3
|
L: (ALRT)
|
16123 |
ALRT |
Alert |
An observation identifying a potential negative occurrence as a result of an Act or combination of Acts. |
3
|
L: (DGIMG)
|
13921 |
DGIMG |
Diagnostic Image |
Class for holding attributes unique to diagnostic images. |
3
|
L: (MPROT)
|
16230 |
MPROT |
Monitoring Program |
An officially or unofficially instituted program to track acts of a particular type or categorization. |
3
|
L: (REFCOORD)
|
16392 |
REFCOORD |
Referenced coordinate |
The Referenced_coordinate class is used to make reference to specific coordinates in images, waveforms or other datasets,
for example, to specify the location of a radiologic finding or to identify the region on which a finding was based. For
instance, clinicians can include graphical images in their notes, and "circle" a particular region of interest. This region
of interest is than specifically referred to in their note. The relationship between a Referenced_coordinate and its referenced
image is specified through an Act_relationship (using an Act_relationship.type_cd value of "REFV"). Referenced_coordinates
are only meaningful in connection with a data object whose contents they reference. The units of the coordinate values are
those of the referenced data object. For example, if the referenced object is a bitmapped image, the coordinates would be
in pixel units. The presence of scaling parameters as attributes in a bitmapped image does not change the sampling coordinates:
they remain in units of pixels. If the referenced object is a vector graphic figure specified in centimeters, the coordinate
values are specified in centimeters.
|
2
|
S: ActSupplyClass (SPLY)
|
11535 |
SPLY |
Supply |
Supply orders and deliveries are simple Acts that focus on the delivered product. The product is associated with the Supply
Act via Participation.type_cd="product". With general Supply Acts, the precise identification of the Material (manufacturer,
serial numbers, etc.) is important. Most of the detailed information about the Supply should be represented using the Material
class. If delivery needs to be scheduled, tracked, and billed separately, one can associate a Transportation Act with the
Supply Act. Pharmacy dispense services are represented as Supply Acts, associated with a Substance_administration Act. The
Substance_administration class represents the administration of medication, while dispensing is supply.
|
3
|
L: (DIET)
|
16109 |
DIET |
Diet |
Diet services are supply services, with some aspects resembling Medication services: the detail of the diet is given as a
description of the Material associated via Participation.type_cd="product". Medically relevant diet types may be communicated
in the Diet.cd attribute using domain ActDietCode, however, the detail of the food supplied and the various combinations of
dishes should be communicated as Material instances.
|
2
|
S: ActWorkingListClass (LIST)
|
11541 |
LIST |
Working List |
Working_list collects a dynamic list of individual instances of Act via Act_relationship which reflects the need of an individual
worker, team of workers, or an organization to manage lists of acts for many different clinical and administrative reasons.
Examples of working lists include problem lists, goal lists, allergy lists, and to-do lists.
|
3
|
A: ActServiceListClass |
10569 |
|
|
|
4
|
S: ActServiceListIssuesClass (ISS)
|
10572 |
ISS |
Issues Service List |
A collections of any kinds of services as issues that need to be resolved. |
5
|
L: (GOL)
|
10574 |
GOL |
goal list |
A patient's goal list as seen by a particular provider. |
5
|
L: (PRB)
|
10573 |
PRB |
problem list |
A patient's problem list as seen by a particular provider. |
4
|
L: (LOG)
|
10571 |
LOG |
logbook |
A diary of past services. |
4
|
L: (SCH)
|
10570 |
SCH |
schedule |
A work-list, a schedule, or a personal to-do list of items intended to be done. |
2
|
L: (ACCM)
|
16137 |
ACCM |
Accomodation |
An accommodation is a service provided for a Person or other Living_subject in which a place is provided for the subject to
reside for a period of time. Commonly used to track the provision of ward, private and semi-private accommodations for a
patient a
|
2
|
L: (CEVN)
|
11534 |
CEVN |
Control event |
The Event is the focal point of information assembled in response to the occurrence of a "controlled event." "Participations"
and "Acts" related to a "controlled event" ard assembled in a package with the RIM content that a domain technical committee
specifies as the main payload of information to be communicated to document the event. This package can be placed in a message
envelope, directed to an application managing documents or any application with component interfaces to this package of structured
information content.
|
2
|
L: (CONS)
|
11537 |
CONS |
Consent |
The Consent class represents informed consents and all similar medico-legal transactions between the patient (or his legal
guardian) and the provider. Examples are informed consent for surgical procedures, informed consent for clinical trials, advanced
beneficiary notice, against medical advice decline from service, release of information agreement, etc.
The details of consents vary. Often an institution has a number of different consent forms for various purposes, including
reminding the physician about the topics to mention. Such forms also include patient education material. In electronic medical
record communication, consents thus are information-generating acts on their own and need to be managed similar to medical
activities. Thus, Consent is modeled as a special class of Act.
The "signatures" to the consent document are represented electronically through Participation instances to the consent object.
Typically an informed consent has Participation.type_cd of "performer" (the healthcare provider informing the patient, and
"consenter", the patient or legal guardian. Some consent may associate a witness or a notary public (e.g., living wills, advanced
directives). In consents where a healthcare provider is not required (e.g. living will), the performer may be the patient
himself or a notary public.
Some consent has a minimum required delay between the consent and the service, so as to allow the patient to rethink his decisions.
This minimum delay can be expressed in the act definition by the Act_relationship.pause_qty attribute that delays the service
until the pause time has elapsed after the consent has been completed.
|
2
|
L: (CONTREG)
|
14005 |
CONTREG |
Container registration |
An Act where a container is registered either via an automated sensor, such as a barcode reader, or by manual receipt |
2
|
L: (CTXT)
|
11533 |
CTXT |
Act Context |
The Act_context is a specialization of an Act that explicitly contains a set of other Acts that share the same context. The
"context" of an act is defined as the attribution ascribed to its containing Act_context.
|
2
|
L: (ENC)
|
11542 |
ENC |
Encounter |
An interaction between a patient and healthcare participant(s) for the purpose of providing patient service(s) or assessing
the health status of a patient. For example, outpatient visit to multiple departments, home health support (including physical
therapy), inpatient hospital stay, emergency room visit, field visit (e.g., traffic accident), office visit, occupational
therapy, telephone call.
|
2
|
L: (PROC)
|
11532 |
PROC |
Procedure |
The term "procedure" is also commonly known as a "surgical procedure" or an "operative procedure". Typically, a surgical procedure
involves planned alteration of the structure of the body, ordinarily requiring the disruption of some body surface, usually
through an incision.
|
2
|
L: (REFR)
|
11538 |
REFR |
Referral |
An introduction of a patient from a source caregiver to a target caregiver or provider institution, typically for the purpose
of obtaining the target caregiver's assessment and treatment recommendations. A referral may authorize a specified quantity
of a particular kind or level of service. A referral may also simply be a recommendation or introduction.
|
2
|
L: (REG)
|
15932 |
REG |
Registration |
Represents the act of maintaining information about an entity or role in a registry. The class is most general, designed
to support a variety of registries for persons, patients, practitioners, equipment, etc. If required, specific registry types
will be treated as specializations of this class.
|
2
|
L: (SBADM)
|
11528 |
SBADM |
Substance Administration |
Substance_administration is an Act using a Material as a therapeutic agent. The effect of the therapeutic substance is typically
established on a biochemical basis, however, that is not a requirement. For example, radiotherapy can largely be described
in the same way, especially if it is a systemic therapy such as radio-iodine.
|
2
|
L: (SPCTRT)
|
14023 |
SPCTRT |
Specimen treatment |
A procedure or treatment performed on a specimen to prepare it for analysis |
2
|
L: (TRNS)
|
11539 |
TRNS |
Transportation |
Transportation is the moving of a payload (people or material) from a location of origin to a destination location. Thus,
any transport service has the three target instances of type payload, origin, and destination, besides the targets that are
generally used for any service (i.e., performer, device, etc.)
|