HL7 Terminology (THO)
6.1.0 - Continuous Process Integration (ci build) International flag

HL7 Terminology (THO), published by HL7 International - Vocabulary Work Group. This guide is not an authorized publication; it is the continuous build for version 6.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/UTG/ and changes regularly. See the Directory of published versions

ValueSet: ActClassRecordOrganizer

Official URL: http://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer Version: 3.0.0
Active as of 2014-03-26 Responsible: Health Level Seven International Computable Name: ActClassRecordOrganizer
Other Identifiers: OID:2.16.840.1.113883.1.11.20308

Copyright/Legal: This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html

No description

References

This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)

Logical Definition (CLD)

Generated Narrative: ValueSet v3-ActClassRecordOrganizer

Language: en

This value set includes codes based on the following rules:

This value set excludes codes based on the following rules:

 

Expansion

Generated Narrative: ValueSet

Language: en

Expansion based on codesystem ActClass v4.0.0 (CodeSystem)

This value set contains 14 concepts

CodeSystemDisplayDefinition
  COMPOSITIONhttp://terminology.hl7.org/CodeSystem/v3-ActClasscomposition

A context representing a grouped commitment of information to the EHR. It is considered the unit of modification of the record, the unit of transmission in record extracts, and the unit of attestation by authorizing clinicians.

A composition represents part of a patient record originating from a single interaction between an authenticator and the record.

Unless otherwise stated all statements within a composition have the same authenticator, apply to the same patient and were recorded in a single session of use of a single application.

A composition contains organizers and entries.

  DOChttp://terminology.hl7.org/CodeSystem/v3-ActClassdocument

The notion of a document comes particularly from the paper world, where it corresponds to the contents recorded on discrete pieces of paper. In the electronic world, a document is a kind of composition that bears resemblance to their paper world counter-parts. Documents typically are meant to be human-readable.

HL7's notion of document differs from that described in the W3C XML Recommendation, in which a document refers specifically to the contents that fall between the root element's start-tag and end-tag. Not all XML documents are HL7 documents.

  DOCCLINhttp://terminology.hl7.org/CodeSystem/v3-ActClassclinical 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.
  CDALVLONEhttp://terminology.hl7.org/CodeSystem/v3-ActClassCDA Level One clinical document

A clinical document that conforms to Level One of the HL7 Clinical Document Architecture (CDA)

  CONTAINERhttp://terminology.hl7.org/CodeSystem/v3-ActClassrecord container

Description: Container of clinical statements. Navigational. No semantic content. Knowledge of the section code is not required to interpret contained observations. Represents a heading in a heading structure, or "container tree".

The record entries relating to a single clinical session are usually grouped under headings that represent phases of the encounter, or assist with layout and navigation. Clinical headings usually reflect the clinical workflow during a care session, and might also reflect the main author's reasoning processes. Much research has demonstrated that headings are used differently by different professional groups and specialties, and that headings are not used consistently enough to support safe automatic processing of the E H R.

  CATEGORYhttp://terminology.hl7.org/CodeSystem/v3-ActClasscategory

A group of entries within a composition or topic that have a common characteristic - for example, Examination, Diagnosis, Management OR Subjective, Objective, Analysis, Plan.

The distinction from Topic relates to value sets. For Category there is a bounded list of things like "Examination", "Diagnosis" or SOAP categories. For Topic the list is wide open to any clinical condition or reason for a part of an encounter.

A CATEGORY MAY CONTAIN ENTRIES.

  DOCBODYhttp://terminology.hl7.org/CodeSystem/v3-ActClassdocument body

A context that distinguishes the body of a document from the document header. This is seen, for instance, in HTML documents, which have discrete <head> and <body> elements.

  DOCSECThttp://terminology.hl7.org/CodeSystem/v3-ActClassdocument section

A context that subdivides the body of a document. Document sections are typically used for human navigation, to give a reader a clue as to the expected content. Document sections are used to organize and provide consistency to the contents of a document body. Document sections can contain document sections and can contain entries.

  TOPIChttp://terminology.hl7.org/CodeSystem/v3-ActClasstopic

A group of entries within a composition that are related to a common clinical theme - such as a specific disorder or problem, prevention, screening and provision of contraceptive services.

A topic may contain categories and entries.

  EXTRACThttp://terminology.hl7.org/CodeSystem/v3-ActClassextract

This context represents the part of a patient record conveyed in a single communication. It is drawn from a providing system for the purposes of communication to a requesting process (which might be another repository, a client application or a middleware service such as an electronic guideline engine), and supporting the faithful inclusion of the communicated data in the receiving system.

An extract may be the entirety of the patient record as held by the sender or it may be a part of that record (e.g. changes since a specified date).

An extract contains folders or compositions.

An extract cannot contain another extract.

  EHRhttp://terminology.hl7.org/CodeSystem/v3-ActClasselectronic health record

A context that comprises all compositions. The EHR is an extract that includes the entire chart.

NOTE: In an exchange scenario, an EHR is a specialization of an extract.

  FOLDERhttp://terminology.hl7.org/CodeSystem/v3-ActClassfolder

A context representing the high-level organization of an extract e.g. to group parts of the record by episode, care team, clinical specialty, clinical condition, or source application. Internationally, this kind of organizing structure is used variably: in some centers and systems the folder is treated as an informal compartmentalization of the overall health record; in others it might represent a significant legal portion of the EHR relating to the originating enterprise or team.

A folder contains compositions.

Folders may be nested within folders.

  GROUPERhttp://terminology.hl7.org/CodeSystem/v3-ActClassgrouper

Definition: An ACT that organizes a set of component acts into a semantic grouping that share a particular context such as timeframe, patient, etc.

UsageNotes: The focus in a GROUPER act is the grouping of the contained acts. For example "a request to group" (RQO), "a type of grouping that is allowed to occur" (DEF), etc.

Unlike WorkingList, which represents a dynamic, shared, continuously updated collection to provide a "view" of a set of objects, GROUPER collections tend to be static and simply indicate a shared set of semantics. Note that sharing of semantics can be achieved using ACT as well. However, with GROUPER, the sole semantic is of grouping.

  CLUSTERhttp://terminology.hl7.org/CodeSystem/v3-ActClassCluster

**Description:**An ACT that organizes a set of component acts into a semantic grouping that have a shared subject. The subject may be either a subject participation (SBJ), subject act relationship (SUBJ), or child participation/act relationship types.

Discussion: The focus in a CLUSTER act is the grouping of the contained acts. For example "a request to cluster" (RQO), "a type of cluster that is allowed to occur" (DEF), etc.

Examples:

  • Radiologic investigations that might include administration of a dye, followed by radiographic observations;
  • "Isolate cluster" which includes all testing and specimen processing performed on a specific isolate;
  • a set of actions to perform at a particular stage in a clinical trial.

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
System The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code

History

DateActionCustodianAuthorComment
2023-11-14reviseTSMGMarc DuteauAdd standard copyright and contact to internal content; up-476
2022-10-18reviseTSMGMarc DuteauFixing missing metadata; up-349
2020-05-06reviseVocabulary WGTed KleinMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26revise2014T1_2014-03-26_001283 (RIM release ID)Vocabulary (Woody Beeler) (no record of original request)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26