# Concepts

Code: 0181
Display: MFN Record-level Error Return
Definition:
Table of codes specifying the status of the requested update.  Site-defined table, specific to each master file being updated via this transaction.


Code: 0184
Display: Department
Definition:
Table of codes specifying the institution department to which this person reports or belongs.  No suggested values.


Code: 0185
Display: Preferred Method of Contact
Definition:
HL7-defined table of codes specifying which of a group of multiple phone numbers is the preferred method of contact for this person.


Code: 0188
Display: Operator ID
Definition:
Table of codes specifying the individual responsible for triggering the event.  No suggested values.


Code: 0189
Display: Ethnic Group
Definition:
Table of codes further defining a patient's ancestry.  In the US, a current use is to use these codes to report ethnicity in line with US federal standards for Hispanic origin.


Code: 0201
Display: Telecommunication Use Code
Definition:
HL7-defined table of codes for specifying a specific use of a telecommunication number.  Best practice is to use this concept whenever a telecommunication number or access string is specified.


Code: 0202
Display: Telecommunication Equipment Type
Definition:
HL7-defined table of codes  for specifying a type of telecommunication equipment.  Best practice is to use this concept whenever a telecommunication number or access string for particular equipment is specified.


Code: 0205
Display: Price Type
Definition:
HL7-defined table of codes used to identify the intent for the dollar amount on a pricing transaction.


Code: 0206
Display: Segment Action Code
Definition:
HL7-defined table of codes specifying actions to be applied for segments when an HL7 version 2 interface is operating in "action code mode" (a kind of update mode in the Standard).


Code: 0208
Display: Query Response Status
Definition:
HL7-defined table of codes defining precise response status concepts in support of HL7 Version 2 query messaging.  It is commonly used to indicate no data is found that matches the query parameters, but no error.


Code: 0209
Display: Relational Operator
Definition:
HL7-defined table of codes used to define the relationship between HL7 segment field names identified in a query construct.


Code: 0210
Display: Relational Conjunction
Definition:
HL7-defined table of codes used with relational operator values to group more than one segment field name.


Code: 0211
Display: Alternate Character Sets
Definition:
Table of codes that identify one of a number of possible standard alternate character sets for a message, either single-byte or double-byte.


Code: 0212
Display: Nationality
Definition:
Table of codes that identify the nation or national grouping to which the person belongs.  This information may be different from a person’s citizenship in countries in which multiple nationalities are recognized (for example, Spain: Basque, Catalan, etc.).  No suggested values.


Code: 0214
Display: Special Program Code
Definition:
Table of codes used to record a health insurance program required for healthcare visit reimbursement.


Code: 0218
Display: Patient Charge Adjustment
Definition:
Table of codes used to indicate which adjustments should be made to a guarantor’s charges.  For example, when a hospital agrees to adjust a guarantor’s charges to a sliding scale.  No suggested values.


Code: 0220
Display: Living Arrangement
Definition:
Table of codes characterizing the situation that patient-associated parties live in at their residential address.


Code: 0222
Display: Contact Reason
Definition:
Table of codes used to indicate a reason for contacting a guarantor, for example, to phone a guarantor if payments are late.  No suggested values.


Code: 0223
Display: Living Dependency
Definition:
Table of codes identifying specific living conditions (e.g., spouse dependent on patient, walk-up) that are relevant to an evaluation of the patient's healthcare needs.


Code: 0225
Display: Escort Required
Definition:
HL7-defined table of codes indicating whether a patient must be accompanied while travelling to a diagnostic service department.


Code: 0227
Display: Manufacturers of Vaccines (code=MVX)
Definition:
Table of codes specifying the organization that manufactures a vaccine. The values are maintained by the US Centers of Disease Control.  Note that the source of truth for these code values are maintained by the CDC, and the code system may be accessed at URL: https://phinvads.cdc.gov/vads/SearchCodeSystems_search.action?searchOptions.searchText=PH_ManufacturersOfVaccinesMVX_CDC_NIP.  The value set is also maintained by the CDC, and may be accessed at URL: https://phinvads.cdc.gov/vads/SearchValueSets_search.action?searchOptions.searchText=PHVS_ManufacturersOfVaccinesMVX_CDC_NIP


Code: 0233
Display: Non-Concur Code/Description
Definition:
Table of codes that specify a non-concur code and description for a denied request, used in insurance claims processing.  No suggested values.


Code: 0234
Display: Report Timing
Definition:
HL7-defined table of codes used to identify the time span of a report or the reason for a report sent to a regulatory agency.


Code: 0236
Display: Event Reported To
Definition:
HL7-defined table of codes used to identify the type of entity to which the event has been reported.


Code: 0239
Display: Event Expected
Definition:
HL7-defined table of codes used to communicate whether an event has been judged to be expected or unexpected.


Code: 0241
Display: Patient Outcome
Definition:
HL7-defined table of codes used to describe the overall state of a patient as a result of patient care.


Code: 0242
Display: Primary Observer's Qualification
Definition:
HL7-defined table of codes used to provide a general description of the kind of health care professional who provided the primary observation.


Code: 0243
Display: Identity May Be Divulged
Definition:
HL7-defined table of codes used to define whether the primary observer has given permission for their identification information to be provided to a product manufacturer.


Code: 0245
Display: Product Problem
Definition:
Table of codes used to indicate if a product problem would exist if a product malfunction could lead to death or serious injury.  No suggested values.


Code: 0248
Display: Product Source
Definition:
HL7-defined table of codes used to describe the evaluation state of a product identified in an incident.


Code: 0249
Display: Generic Product
Definition:
Table of codes used to indicate whether the product used is a generic or a branded product. No suggested values.


Code: 0250
Display: Relatedness Assessment
Definition:
HL7-defined table of codes used to provide an estimate of whether an issue with a  product was the cause of an event.


Code: 0251
Display: Action Taken in Response to the Event
Definition:
HL7-defined table of codes used to define the action taken as a result of an event related to a product issue.


Code: 0252
Display: Causality Observations
Definition:
HL7-defined table of codes used to record event observations regarding what may have caused a product related event.


Code: 0253
Display: Indirect Exposure Mechanism
Definition:
HL7-defined table of codes used to identify the mechanism of product transmission when the product has not been directly applied to the patient.


Code: 0254
Display: Kind of Quantity
Definition:
HL7-defined table of codes that describe the underlying kind of property represented by an observation.  The categories distinguish concentrations from total amounts, molar concentrations from mass concentrations, partial pressures from colors, and so forth.  These are discussed more fully in the LOINC Users' Manual.   They are derived from the approach described in 1995 edition of the IUPAC Silver Book.  These distinctions are used in IUPAC and LOINC standard codes.  The distinctions of true quantities in this table are based primarily on dimensional analyses. The table contains a number of "families," those related to simple counts (number, number concentration, etc.), to mass (mass, mass concentration, etc.), to enzyme activity (catalytic content, catalytic concentration, etc.), and molar or equivalents (substance content, substance concentration).


Code: 0255
Display: Duration Categories
Definition:
Table of codes used to classify an observation definition as intended to measure a patient's state at a point in time.


Code: 0256
Display: Time Delay Post Challenge
Definition:
HL7-defined table of codes used to classify an observation definition as being a component of a challenge test.


Code: 0257
Display: Nature of Challenge
Definition:
HL7-defined table of codes used to further describe an observation definition that is characterized as a challenge observation.


Code: 0258
Display: Relationship Modifier
Definition:
HL7-defined table of codes used in an observation definition to describe the subject of an observation in relation to a patient.


Code: 0259
Display: Modality
Definition:
Table of codes used to define the imaging apparatus expected to be used to acquire an observation.  This table has been removed from the standard as of 2.7 in favor of table 0910.


Code: 0261
Display: Location Equipment
Definition:
Table of codes used to identify the equipment available in a location definition identified as a room or bed.


Code: 0262
Display: Privacy Level
Definition:
Table of codes used to identify the level of privacy a patient will be afforded when assigned to this location definition.


Code: 0263
Display: Level of Care
Definition:
Table of codes used to identify the level of care a patient may be afforded when assigned to this location definition.


Code: 0264
Display: Location Department
Definition:
Table of codes used to specify the institution’s department to which a location belongs, or its cost center.


Code: 0265
Display: Specialty Type
Definition:
Table of codes used to identify the specialty of the care professional who is supported when using this location definition.


Code: 0267
Display: Days of the Week
Definition:
HL7-defined table of codes used to identify the day(s) of the week when a location may be scheduled for appointments.


Code: 0268
Display: Override
Definition:
Table of codes used to define whether a Charge Description Master description may be overridden or if it must be overridden.


Code: 0272
Display: Document Confidentiality Status
Definition:
HL7-defined table of codes that specify the degree to which special confidentiality protection should be applied to  information.  The assignment of data elements to these categories is left to the discretion of the healthcare organization.


Code: 0273
Display: Document Availability Status
Definition:
HL7-defined table of codes used to define whether a patient document is appropriate or available for use in patient care.


Code: 0275
Display: Document Storage Status
Definition:
HL7-defined table of codes used to describe the availability of a document in relation to the type of storage.


Code: 0276
Display: Appointment reason codes
Definition:
Table of codes used to describe the kind of appointment or the reason why an appointment has been scheduled.


Code: 0278
Display: Filler status codes
Definition:
Table of codes used to describe an appointment status from the perspective of the entity assigned to fulfill the appointment.


Code: 0279
Display: Allow Substitution Codes
Definition:
Table of codes used to indicate whether the appointment resource may be substituted for another by the entity assigned to fulfill the appointment.


Code: 0281
Display: Referral Type
Definition:
Table of codes used to identify the general category of healthcare professional desired to satisfy a referral.


Code: 0282
Display: Referral Disposition
Definition:
Table of codes used to identify the expected response from the healthcare professional receiving a referral.


Code: 0285
Display: Insurance Company ID Codes
Definition:
Table of codes specifying the identification of the insurance company or other entity that administers the authorizing coverage plan.  No suggested values.


Code: 0286
Display: Provider Role
Definition:
Table of codes used to define the relationship between a referral recipient and a patient or between a referral initiator and a patient.


Code: 0288
Display: Census Tract
Definition:
Table of codes specifying the census tract in which the specified address resides.  No suggested values.


Code: 0289
Display: County/Parish
Definition:
Table of codes specifying the county or parish in which the specified address resides.  No suggested values.


Code: 0290
Display: MIME base64 encoding characters
Definition:
Table of encoding characters used for base64 MIME encoding.  Base64 is defined as follows (adapted from MIME Internet standard RFC 1521).


Code: 0291
Display: Subtype of Referenced Data
Definition:
Table of codes specifying a subset of the media subtypes of binary data that are encoded in an ascii structure or stream.


Code: 0292
Display: Vaccines Administered
Definition:
Table of codes specifying the administered vaccines.   The values are maintained by the US Centers of Disease Control.  The code system is maintained by the CDC, and may be found at URL;  https://phinvads.cdc.gov/vads/ViewCodeSystem.action?id=2.16.840.1.113883.12.292
The value set is maintained by the CDC and may be found at URL: https://phinvads.cdc.gov/vads/ViewValueSet.action?id=ABDEE003-77C3-48E7-B941-EBF92B6B81FC


Code: 0293
Display: Billing Category
Definition:
Table of codes specifying the billing category codes for any classification systems needed, for example, general ledger codes and UB92 categories.  No suggested values.


Code: 0294
Display: Time Selection Criteria Parameter Class Codes
Definition:
Table of codes used to describe acceptable start and end times, as well as days of the week, for appointment or resource scheduling.


Code: 0298
Display: CP Range Type
Definition:
HL7-defined table of codes that specify whether a composite price range is experssed as a flat rate or a percentage.


Code: 0299
Display: Encoding
Definition:
HL7-defined table of codes identifying the type of encoding used to represent successive octets of binary data as displayable ASCII characters.  These are defined by IETF; more information may be found at https://www.ietf.org/rfc/rfc1521.txt


Code: 0300
Display: Namespace ID
Definition:
Table of codes which specify the unique name of the system that stores the data.   It was previously named the Application ID.  No suggested values.


Code: 0301
Display: Universal ID Type
Definition:
HL7-defined table of codes specifying the type of UID (Universal Identifier).  Open Issue:  Table 0301 has a mix of class and instance identifiers for namespaces, which is improper.  The values for instances. such as CLIA, CLIP, CAP, and NPI. These were added for pragmatic issues related to older datatypes that were universally bound tand should not be here but are needed for implementation pragmatics.   These should be annotated in Comment or Usage Notes that these are not universal ID types really.


Code: 0302
Display: Point of Care
Definition:
Table of codes specifying the point where patient care is administered.  It is conditional on Person Location Type (e.g., nursing unit or department or clinic).   No suggested values.


Code: 0306
Display: Location Status
Definition:
Table of codes specifying the status or availability of the location, such as the bed status.   No suggested values.


Code: 0309
Display: Coverage Type
Definition:
Table of codes specifying the type of insurance coverage or what types of services are covered for the purposes of a billing system.  For example, a physician billing system will only want to receive insurance information for plans that cover physician/professional charges.


Code: 0312
Display: Policy Scope
Definition:
Table of codes specifying the extent of insurance coverage for a participating member (e.g., single, family, etc.).  No suggested values.


Code: 0315
Display: Living Will Code
Definition:
Table of codes specifying whether or not the patient has a living will and, if so, whether a copy fo the living will is on file at the healthcare facility.  If the patient does not have a living will, the value of this field indicates whether the patient was provided information on living wills.


Code: 0316
Display: Organ Donor Code
Definition:
Table of codes specifying whether the patient wants to donate his/her organs and whether an organ donor card or similar documentation is on file with the healthcare organization.


Code: 0317
Display: Annotations
Definition:
Table of codes specifying the coded entry associated with a given point in time during the waveform recording.  Note codes beyond 9903 may exist; extensions to this table may be done by incrementing the code value.


Code: 0319
Display: Department Cost Center
Definition:
Table of codes specifying the accounting code that identifies the department in order to charge for the item.  No suggested values.


Code: 0323
Display: Action Code
Definition:
HL7-defined table ofstatus codes of record operation. Used in Version 2 messaging, these are used in the RXA segment in the vaccine messages, where a method of correcting vaccination information transmitted with incorrect patient identifying information is needed.  As of version 2.6, this table was replaced with table 0206, whose values are defined by code system 2.16.840.1.133883.18.111.


Code: 0324
Display: Location Characteristic ID
Definition:
Table of codes specifying an identifier code to show which characteristic is being communicated with the segment.


Code: 0325
Display: Location Relationship ID
Definition:
Table of codes specifying an identifier code to show which relationship is being communicated with the segment.


Code: 0326
Display: Visit Indicator
Definition:
Table of codes specifying the level on which data are being sent.  It is the indicator used to send data at two levels, visit and account.  HL7 recommends sending an "A" or no value when the data in the message are at the account level or "V" to indicate that the data sent in the message are at the visit level.


Code: 0329
Display: Quantity Method
Definition:
HL7-defined table of codes used to specify the method by which the quantity distributed is measured.


Code: 0332
Display: Source Type
Definition:
HL7-defined table of codes used to indicate (in certain systems) whether a lower level source identifier is an initiate or accept type.


Code: 0334
Display: Disabled Person Code
Definition:
Table of codes used to specify to which person the disability information relates in the message.  For example, if the value is PT, the disability information relates to the patient.


Code: 0335
Display: Repeat Pattern
Definition:
Table of codes used to specify the interval between repeated services. See the Comment/Usage Note in the table below, as the table contains both precoordinated codes that may be used in an HL7 field or component and also explanatory patterns illustrating the syntax used to construct expressions using the codes and other modifiers.


Code: 0337
Display: Certification Status
Definition:
HL7-defined table of codes used to specify the status of the practitioner's speciality certification.


Code: 0339
Display: Advanced Beneficiary Notice Code
Definition:
Table of codes specifying the status of the patient's or the patient's representative's consent for responsibility to pay for potentially uninsured services. This element was introduced to satisfy CMS Medical Necessity requirements for outpatient services in the United States. Includes concepts such as (a) whether the associated diagnosis codes for the service are subject to medical necessity procedures, (b) whether, for this type of service, the patient has been informed that they may be responsible for payment for the service, and (c) whether the patient agrees to be billed for this service.


Code: 0340
Display: Procedure Code Modifier
Definition:
Table of codes that specify a procedure code modifier to a procedure code.  Procedure code modifiers are defined by regulatory agencies such as CMS and the AMA.  Multiple modifiers may be reported.  The modifiers are sequenced in priority according to user entry.  This is a requirement of the UB and the 1500 claim forms.  Multiple modifiers are allowed and the order placed on the form affects reimbursement.


Code: 0342
Display: Military Recipient
Definition:
Table of codes that specify a designation as a military recipient.  This field is defined by CMS or other regulatory agencies.  No suggested values.


Code: 0343
Display: Military Handicapped Program Code
Definition:
Table of codes that specify a military program for the handicapped in which a patient is enrolled.  No suggested values.


Code: 0344
Display: Patient's Relationship to Insured
Definition:
Table of codes used to specify the relationship of the patient to the insured, as defined by CMS or other regulatory agencies.


Code: 0345
Display: Appeal Reason
Definition:
Table of codes that specify  reasons an appeal was made on a non-concur for certification.  No suggested values.


Code: 0347
Display: State/Province
Definition:
Table of codes specifying the names of the principal country subdivisions (e.g., provinces or states).  The values in the table are country specific.  For example, in the US, the Federal Information Processing Standard (FIPS) alpha codes may be used by local agreement.


Code: 0348
Display: Special Program Indicator
Definition:
Table of codes that specify the special program indicator, as described in the UB82 Field 44.  This field is defined by HCFA or other regulatory agencies in the US.  Note that The UB codes listed as examples in earlier released of the HL7 Standards are not an exhaustive or current list; refer to a UB specification for additional information


Code: 0349
Display: PSRO/UR Approval Indicator
Definition:
HL7-defined table of codes of PSRO/UR approval indicators, as used in the UB82 field 87.  This field is defined by HCFA (in the US) or other regulatory agencies.  Note that this form type is no longer used in the US, and the  codes listed (as examples) are not an exhaustive or current list; refer to a UB84 specification for additional information.


Code: 0350
Display: Occurrence Code
Definition:
Table of codes that specify a National Uniform Billing Committee (NUBC) code for the event or occurrence relating to a bill that may affect payer processing.  In the US, NUBC codes generally used, see code system 2.16.840.1.113883.6.301.7; more information may be found at  http://www.nubc.org/become.html


Code: 0351
Display: Occurrence Span
Definition:
Externally defined table of codes specifying a National Uniform Billing Committee (NUBC) code that identifies an event that relates to the payment of a claim.  In the US, NUBC codes generally used, see code system 2.16.840.1.113883.6.301.8; more information may be found at  http://www.nubc.org/become.html.  The UB-04 Data Specifications Manual with the codes is available by subscription from NUBC at http://www.nubc.org/become.html.


Code: 0353
Display: CWE statuses
Definition:
HL7-defined table of codes that represent an exception identifier code; that is, a code that is not defined in the value set (either model or site-extended).  These are occationsally referred to a 'flavors of null' although this set of concepts is specific to the CWE datatype used in Version 2 messaging, and the codes may be used in the 'identifier' component of the 'triplets' in that datatype.


Code: 0354
Display: Message Structure
Definition:
HL7-defined table of abstract message structure codes. Each code identifies a specific message structure abstract syntax as published in the HL7 Version 2 standard.


Code: 0356
Display: Alternate Character Set Handling Scheme
Definition:
HL7-defined table of codes that specify the scheme used when any alternative character sets are specified in the second or later iterations of MSH-18 Character Set, and if any special handling scheme is needed.


Code: 0358
Display: Practitioner Group
Definition:
Table of codes specifying the name and/or code of a group of practitioners to which this practitioner belongs.  No suggested values.


Code: 0359
Display: Diagnosis Priority
Definition:
Table of codes that identify the significance or priority of the diagnosis code.  Note that the codes are numeric, and the number of the code represents the ordinal priority of the associated diagnosis. The predefined codes are the most common, and just a starter set, as the codes are an unbounded list; additional ranked procedures may be signified by incrementing the code value as needed.


Code: 0360
Display: Degree/License/Certificate
Definition:
Table of codes specifying an educational degree (e.g., MD).  Used in the CNN datatype (names and identifiers of clinicians) in Version 2 messaging.


Code: 0361
Display: Application
Definition:
Table of codes that identify a sending application among all other applications within the network enterprise.  The network enterprise consists of all those applications that participate in the exchange of HL7 messages within the enterprise.  No suggested values.


Code: 0362
Display: Facility
Definition:
Table of codes specifying the site-specific name for the facility used by this application.  No suggested values.


Code: 0363
Display: Assigning Authority
Definition:
Table of codes specifying a unique name of the system (or organization or agency or department) that creates the data.  No suggested values.


Code: 0365
Display: Equipment State
Definition:
HL7-defined table of codes that identify the status the equipment was in at the time the transaction was initiated.


Code: 0366
Display: Local/Remote Control State
Definition:
HL7-defined table of codes that identify the current state of control associated with the equipment.   Equipment can either work autonomously ('Local' control state) or it can be controlled by another system, e.g., LAS computer ('Remote' control state).


Code: 0367
Display: Alert Level
Definition:
HL7-defined table of codes that identify the highest level of the alert state (e.g.,highest alert severity) that is associated with the indicated equipment (e.g. processing event, inventory event, QC event).


Code: 0370
Display: Container Status
Definition:
HL7-defined table of codes that identify the status of the unique container in which the specimen resides at the time the transaction was initiated.


Code: 0371
Display: Additive/Preservative
Definition:
HL7-defined table of codes specifying any additive introduced to the specimen before or at the time of collection.  These additives may be introduced in order to preserve, maintain or enhance the particular nature or component of the specimen.


Code: 0374
Display: System Induced Contaminants
Definition:
Table of codes that identify the specimen contaminant identifier associated with the specimen in the container.


Code: 0376
Display: Special Handling Code
Definition:
Table of codes describing how a specimen and/or container needs to be handled from the time of collection through the initiation of testing.


Code: 0377
Display: Other Environmental Factors
Definition:
Table of codes that identify the other environmental factors associated with the specimen in a specific container, e.g., atmospheric exposure.


Code: 0378
Display: Carrier Type
Definition:
Table of codes that identify a type of carrier.  Because the geometry can be different, the carrier type should, if possible, express the number of positions in the carrier.  The definition assumes hierarchical nesting using the following phrases: container is located in a carrier, carrier is located in a tray.  No suggested values.


Code: 0379
Display: Tray Type
Definition:
Table of codes that identify a type of tray.  Because the geometry can be different, the tray type should, if possible, express the number of positions in the tray.  The definition assumes hierarchical nesting using the following phrases: container is located in a carrier, carrier is located in a tray.  No suggested values.


Code: 0380
Display: Separator Type
Definition:
Table of codes that identify a type of separator being used (e.g., a gel separator in a container - not to be confused with the communication separators).  It is recommended the first table entry be "NO" meaning "No Separator".  No suggested values.


Code: 0381
Display: Cap Type
Definition:
Table of codes that identify a type of cap that is to be used with a container for decapping, piercing or other mechanisms.  No suggested values.


Code: 0383
Display: Substance Status
Definition:
HL7-defined table of codes identifying the status of the inventoried item.  The status indicates the current status of the substance.


Code: 0385
Display: Manufacturer Identifier
Definition:
Table of codes that identify a manufacturer of a substance.  Relevant external code systems may be used, e.g., HIBCC Manufacturers Labeler ID Code (LIC), UPC, NDC, etc.  No suggested values.


Code: 0388
Display: Processing Type
Definition:
HL7-defined table of codes identifying the processing type that applies to the test code.  If this attribute is omitted, then regular production is the default.


Code: 0389
Display: Analyte Repeat Status
Definition:
HL7-defined table of codes identifying the repeat status for the analyte/result (e.g. original, rerun, repeat, reflex).  The following are assumptions regarding the table values: Repeated without dilution — performed usually to confirm correctness of results (e.g., in case of results flagged as "Panic" or mechanical failures).  Repeated with dilution — performed usually in the case the original result exceeded the measurement range (technical limits).  Reflex test — this test is performed as the consequence of rules triggered based on other test result(s).


Code: 0391
Display: Segment Group
Definition:
HL7-defined table of codes specifying the optional segment groups which are to be included in a response.


Code: 0392
Display: Match Reason
Definition:
Table of codes identifying what search components (e.g., name, birthdate, social security number) of the record returned matched the original query where the responding system does not assign numeric match weights or confidence levels.  It provides a method for passing a descriptive indication of the reason a particular record was found.


Code: 0393
Display: Match Algorithms
Definition:
Table of codes identifying the name or identity of the specific search algorithm to which the RCP-5 Search Confidence Threshold and the QRI-1 Candidate Confidence refer.


Code: 0396
Display: Coding System
Definition:
HL7-defined table of specifying the coding system.  This table is maintained outside of the published Version 2 standards; the content is not listed here; the content is maintained outside of the Version 2 Product Family maintenance process.  For the list of codes in the table, see the HL7 Webpage rendering, at http://www.hl7.org/Special/committees/vocab/table_0396/index.cfm.


Code: 0397
Display: Sequencing
Definition:
HL7-defined table of codes identifying how the field or parameter will be sorted and, if sorted, whether the sort will be case sensitive (the default) or not.


Code: 0398
Display: Continuation Style Code
Definition:
HL7-defined table of codes identifying whether it is a fragmented message or part of an interactive continuation message.


Code: 0399
Display: Country Code
Definition:
Table of codes that identifies a country of origin for a message.  It will be used primarily to specify default elements, such as currency denominations. The values to be used are those of ISO 3166. The ISO 3166 table has three separate forms of the country code: HL7 specifies that the 3-character (alphabetic) form be used for the country code.


Code: 0401
Display: Government Reimbursement Program
Definition:
Table of codes which specify codes that indicate an agency that the practitioner is authorized to bill for medical services.  Existing codes only for use in the United States.


Code: 0402
Display: School Type
Definition:
Table of codes which specify a categorization of an academic institution that grants a degree to a Staff Member.


Code: 0403
Display: Language Ability
Definition:
Table of codes which specify codes that indicate the ability that a Staff Member possesses with respect to the language.


Code: 0404
Display: Language Proficiency
Definition:
HL7-defined table of codes which specify the level of knowledge a person possesses with respect to a language ability identified.


Code: 0405
Display: Organization Unit
Definition:
Table of codes which specify the hierarchical components of an organization unit, as defined by the institution.  No suggested values.


Code: 0406
Display: Participant Organization Unit Type
Definition:
HL7-defined table of codes that specify the environment in which the provider acts in the role associated with the provider type, and inludes codes for venues outside of formal organized healthcare settings, such as Home. The provider environment is not the specialty for the provider.


Code: 0409
Display: Application Change Type
Definition:
HL7-defined table of codes that specify a type of change being requested (if NMR query) or announced (if NMD unsolicited update).


Code: 0411
Display: Supplemental Service Information Values
Definition:
Table of codes that specify supplemental service information sent between a placer system and a filler system for the universal procedure code reported in OBR-4 Universal Service ID. This specifies ordering information detail that is not available in other specific tables for fields in the OBR segment.  These might be details such as whether a study is to be done on the right or left, for example, where the study is of the arm and the order master file does not distinguish right from left, or whether a study is to be done with or without contrast (when the order master file does not make such distinctions).


Code: 0412
Display: Category Identifier
Definition:
Table of codes that specify a category name (term given to a group of service items for the purpose of classification). Examples: Laboratory, Pharmacy, Diagnostic Imaging, etc.  No suggested values.


Code: 0413
Display: Consent Identifier
Definition:
Table of codes that provide an identifier for the consent specified for a service item.  No suggested values.


Code: 0415
Display: Transfer Type
Definition:
HL7-defined table of codes that specify a type of hospital receiving a transfer patient, which affects how a facility is reimbursed under diagnosis related group (DRG's), for example, exempt or non-exempt.


Code: 0418
Display: Procedure Priority
Definition:
HL7-defined table of codes specifying a number that identifies the significance or priority of the procedure code.


Code: 0423
Display: Case Category Code
Definition:
Table of codes specifying the reason a non-urgent patient presents to the emergency room for treatment instead of a clinic or physican office.


Code: 0429
Display: Production Class Code
Definition:
Table of codes specifying the code and/or text indicating the primary use for which the living subject was bred or grown.


Code: 0434
Display: Patient Condition Code
Definition:
Table of codes specifying the patient's current medical condition for the purpose of communicating to non-medical outside parties, e.g. family, employer, religious minister, media, etc.


Code: 0443
Display: Provider Role
Definition:
Table of codes specifying the functional involvement with the activity being transmitted (e.g., Case Manager, Evaluator, Transcriber, Nurse Care Practitioner, Midwife, Physician Assistant, etc.).


Code: 0444
Display: Name Assembly Order
Definition:
HL7-defined table of codes specifying the preferred display order of the components of this person name.


Code: 0445
Display: Identity Reliability Code
Definition:
Table of codes specifying the reliability of patient/person identifying data transmitted via a transaction.


Code: 0449
Display: Conformance statements
Definition:
HL7-defined table of reasons a specimen may be rejected for a specified observation/result/analysis.  Used in Version 2 messaging in the SPM segment.


Code: 0452
Display: Health Care Provider Type Code
Definition:
Table of codes specifying the major grouping of the service or occupation of the practitioner at a specific organization unit.   In the US, it is suggested to use ANSI ASC X12 Health Care Provider Taxonomy, Level 1 - Type


Code: 0453
Display: Health Care Provider Classification
Definition:
Table of codes specifying the more specific service or occupation within the healthcare provider type of the practitioner at a specific organization unit. Health Care Provider ClassificationIn the US, it is suggested to use ANSI ASC X12 Health Care Provider Taxonomy, Level 2 - Classification


Code: 0454
Display: Health Care Provider Area of Specialization
Definition:
Table of codes specifying the segment of the population that a health care provider chooses to service, a specific medical service, a specialization in treating a specific disease, or any other descriptive characteristic about the provider’s practice relating to the services rendered of the practitioner at a specific organization unit.Health Care Provider Area of Specialization.  In the US it is suggested to use ANSI ASC X12 Health Care Provider Taxonomy, Level 2 - Classification.


Code: 0455
Display: Type of Bill Code
Definition:
Table of codes specifying the specific type of bill with digit 1 showing type of facility, digit 2 showing bill classification and digit 3 showing frequency.  No suggested values.


Code: 0456
Display: Revenue code
Definition:
Externally defined table of codes specifying a service line revenue code.  These are claim codes indicating the identifying number for the product or service provided.  In the US, NUBC codes generally used, see code system 2.16.840.1.113883.6.301.3; more information may be found at  http://www.nubc.org/become.html. The UB-04 Data Specifications Manual with the codes is available by subscription from NUBC at http://www.nubc.org/become.html, UB form locater 42.


Code: 0458
Display: OCE Edit Code
Definition:
Table of codes that specify the edits that result from processing the HCPCS/CPT procedures for a record after evaluating all the codes, revenue codes, and modifiers.  The codes listed as examples are not an exhaustive or current list, refer to OPPS Final Rule.  OCE (Outpatient Code Editor) edits also exist at the pre-procedure level.  This field is defined by CMS or other regulatory agencies.


Code: 0463
Display: Inventory Number
Definition:
Table of codes specifying an identifying stock number, if any, which might be used, for example, as a cross reference for materials management.  No suggested values.


Code: 0464
Display: Facility ID
Definition:
Table of codes specifying the facility of the institution for which this price (for the preceding CDM entry) is valid.  For use when needing multi-facility pricing. If null, assume all facilities. In a multi-facility environment, the facility associated with this chargeable item may not be the same as the sending or receiving facility identified in the MSH segment. Use only when the price is not the same for all facilities, that is, a null value indicates that this pricing is valid for all facilities.  No suggested values.


Code: 0465
Display: Name/Address Representation
Definition:
HL7-defined table of codes specifying an indication of the representation provided by the data item.


Code: 0467
Display: Modifier Edit Code
Definition:
Table of codes that specify the edits of the modifiers for each line or HCPCS/CPT.  This field is defined by CMS or other regulatory agencies in the US.


Code: 0472
Display: TQ Conjunction ID
Definition:
HL7-defined table of codes specifying that a second timing specification is to follow using the repeat delimiter.


Code: 0475
Display: Charge Type Reason
Definition:
Table of codes specifying the choice of, and providing the clinical rationale for, a selected charge type.


Code: 0476
Display: Medically Necessary Duplicate Procedure Reason
Definition:
Table of codes specifying the reason the procedure code found in OBR-44 Procedure Code is a duplicate of one ordered/charged previously for the same patient within the same date of service and has been determined to be medically necessary.  No suggested values.


Code: 0477
Display: Controlled Substance Schedule
Definition:
Table of codes specifying the class of the drug or other substance if its usage is controlled by legislation.  In the USA, such legislation includes the federal Controlled Substance Act (CSA) or a State Uniform Controlled Substance Act. Values are drawn from the Pharmacy Law Digest July 1988.  Other countries should create their own versions of this table.  No suggested values.


Code: 0478
Display: Formulary Status
Definition:
HL7-defined table of codes specifying whether or not the pharmaceutical substance is part of the local formulary.


Code: 0479
Display: Pharmaceutical Substances
Definition:
Table of codes specifying the medical substance or treatment that has been ordered to be given to the patient, as encoded by the pharmacy or treatment supplier.  No suggested values.


Code: 0480
Display: Pharmacy Order Types
Definition:
HL7-defined table of codes specifying the general category of pharmacy order which may be used to determine the processing path the order will take.


Code: 0482
Display: Order Type
Definition:
HL7-defined table of codes specifying whether the order is to be executed in an inpatient setting or an outpatient setting.


Code: 0483
Display: Authorization Mode
Definition:
HL7-defined table of codes of forms of authorization a recorder may receive from the responsible practitioner to create or change an order.


Code: 0485
Display: Extended Priority Codes
Definition:
Table of codes describing the urgency of a request carried in an order. See the Comment/Usage Note in the table below, as the table contains both precoordinated codes that may be used in an HL7 field or component and also explanatory patterns illustrating the syntax used to construct expressions using the codes and other modifiers.


Code: 0487
Display: Specimen Type
Definition:
HL7-defined table of codes that describe the precise nature of an entity that may be used as the source material for an observation.  This is one of two code systems that are used instead of table 0070 (code system 2.16.840.1.113883.18.28) which conflated specimen types and specimen collection methods.


Code: 0488
Display: Specimen Collection Method
Definition:
HL7-defined table of codes specifying the specimen collection method.   Used in Version 2 messaging in the SPM segment.


Code: 0489
Display: Risk Codes
Definition:
Table of codes specifying any known or suspected specimen hazards, e.g., exceptionally infectious agent or blood from a hepatitis patient.


Code: 0490
Display: Specimen Reject Reason
Definition:
HL7-defined table of codes specifying the reasons a specimen may be rejected for a specified observation/result/analysis.


Code: 0492
Display: Specimen Appropriateness
Definition:
Table of codes specifying the suitability of the specimen for the particular planned use as determined by the filler.


Code: 0494
Display: Specimen Child Role
Definition:
HL7-defined table of codes specifying for child specimens the relationship between this specimen and the parent specimen.


Code: 0496
Display: Consent Type
Definition:
Table of codes specifying to what the subject is consenting, i.e. what type of service, surgical procedure, information access/release or other event.


Code: 0500
Display: Consent Disclosure Level
Definition:
HL7-defined table of codes used to specify how much information was disclosed to the subject as part of the informed consent process.


Code: 0502
Display: Non-Subject Consenter Reason
Definition:
HL7-defined table of codes used to specify a reason consent was granted by a person other than the subject of the consent.


Code: 0503
Display: Sequence/Results Flag
Definition:
HL7-defined table of codes used to specify the sequencing relationship between the current service request and the related service request(s) specified in this TQ2 segment.


Code: 0504
Display: Sequence Condition Code
Definition:
HL7-defined table of codes used to specify the relationship between the start/end of the related service request(s) (from TQ2-3, TQ2-4 or TQ2-5) and the current service request from ORC-2, 3 or 4.


Code: 0505
Display: Cyclic Entry/Exit Indicator
Definition:
HL7-defined table of codes used to specify if this service request is the first or last service request in a cyclic series of service requests.


Code: 0506
Display: Service Request Relationship
Definition:
HL7-defined table of codes used to specify an additional or alternate relationship between this service request and other service requests.


Code: 0507
Display: Observation Result Handling
Definition:
Table of codes regarding the handling of a result.  For example, an order may specify that the result (e.g., an x-ray film) should be given to the patient for return to the requestor.


Code: 0508
Display: Blood Product Processing Requirements
Definition:
Table of codes used to specify additional information about the blood component class associated with the Universal Service ID.  The placer of the order can specify any required processing of the blood product that must be completed prior to transfusion to the intended recipient.


Code: 0510
Display: Blood Product Dispense Status
Definition:
HL7-defined table of codes used to specify the current status of the specified blood product as indicated by the filler or placer.  For example, the first status change of a product that may trigger a Blood Product Dispense Status Message occurs when it first becomes linked to a patient and is ready to dispense. The placer system may use the Blood Product Dispense Status Message to request the transfusion service to dispense the product.  When the blood product is delivered or issued to a patient, the status of the blood product would be changed to indicate that it has now been "dispensed".


Code: 0511
Display: BP Observation Status Codes Interpretation
Definition:
HL7-defined table of codes used to specify the interpretation for the blood product observation status codes.  A status is considered preliminary until a blood product has reached a final disposition for the patient. For example, when the product is first cross-matched and a status message is sent, it would be considered preliminary. When the product is dispensed to the patient, that status would also be considered preliminary.  However, once the product is transfused, the status would be considered final.


Code: 0512
Display: Commercial Product
Definition:
Table of codes that specify a commercial product.  Examples of commercial products are blood derivatives such as Rh Immune Globulin and Factor VIII concentrate, Leukoreduction filters and blood administration sets.  No suggested values.


Code: 0513
Display: Blood Product Transfusion/Disposition Status
Definition:
HL7-defined table of codes used to specify the current status of the specified blood product as indicated by the placer.  For example, the placer may return the blood product to the transfusion service unused because an IV could not be started. The blood component may have been entered, but the line was clogged and could not be used, in which case the component must be wasted. A final status would indicate that the product has actually been "transfused."


Code: 0514
Display: Transfusion Adverse Reaction
Definition:
Table of codes used to specify the type of adverse reaction that the recipient of the blood product experienced.


Code: 0515
Display: Transfusion Interrupted Reason
Definition:
Table of codes that specify the reason the transfusion of the blood product was interrupted.  No suggested values.


Code: 0516
Display: Error Severity
Definition:
HL7-defined table of codes specifying the severity of an application error as reported during acknowledgment of messages. Knowing if something is Error, Warning or Information is intrinsic to how an application handles the content and the information flow.


Code: 0517
Display: Inform Person Code
Definition:
Table of codes used to specify who (if anyone) should be informed of the error.  This field may also be used to indicate that a particular person should NOT be informed of the error (e.g. do not inform patient.)


Code: 0518
Display: Override Type
Definition:
Table of codes used to specify what type of override can be used to override the specific error identified.


Code: 0519
Display: Override Reason
Definition:
Table of codes that specify the override codes that can be used to override enforcement of the application rule that generated an error.  No suggested values.


Code: 0520
Display: Message Waiting Priority
Definition:
HL7-defined table of codes used to specify how important the most important waiting mesasge is.  For example, if there are 3 low priority messages, 1 medium priority message and 1 high priority message, the message waiting priority would be "high", because that is the highest priority of any new message waiting.


Code: 0523
Display: Computation Type
Definition:
HL7-defined table of codes used to specify if the change is computed as a percent change or as an absolute change.


Code: 0524
Display: Sequence condition
Definition:
HL7-defined table of codes that identify whether sequence conditions or a repeating cycle of orders is defined.   This is part of the Order Sequence Definition.


Code: 0527
Display: Calendar Alignment
Definition:
HL7-defined table of codes used to specify an alignment of the repetition to a calendar (e.g., to distinguish every  30 days from "the 5th of every month").


Code: 0529
Display: Precision
Definition:
HL7-defined table of concepts used to specify the degree of precision of the time stamp.   Table is no longer published as part of the released Standard after version 2.5.1.


Code: 0530
Display: Organization, Agency, Department
Definition:
Table of codes used to specify the agency or department that assigned the identifier in component 1.


Code: 0531
Display: Institution
Definition:
Table of codes that specify the institution where a staff member is or was active.  No suggested values.


Code: 0532
Display: Expanded Yes/no Indicator
Definition:
HL7-defined table of codes used to specify an expansion on the original Yes/No indicator table by including "flavors of null".  It is intended to be applied to fields where the response is not limited to "yes" or "no".


Code: 0533
Display: Application Error Code
Definition:
Table of codes that specify the application specific code identifying the specific error that occurred.  No suggested values.


Code: 0535
Display: Signature Code
Definition:
Table of codes that indicate how a patient/subscriber authorization signature is obtained and how it is being retained by a provider.


Code: 0537
Display: Institution
Definition:
Table of codes that specify the institution the practitioner began or intends to begin practicing at (e.g., at hospital, at physician organization, at managed care network).  No suggested values.


Code: 0538
Display: Institution Relationship Type
Definition:
Table of codes used to specify the relationship the staff person has with the institution for whom he/she provides services.


Code: 0539
Display: Cost Center Code
Definition:
Table of codes that specify the organization unit in the General Ledger to which the staff member is currently assigned.  No suggested values.


Code: 0541
Display: Specimen Type Modifier
Definition:
Table of codes that specify the modifying or qualifying description(s) about the specimen type.  No suggested values.


Code: 0542
Display: Specimen Source Type Modifier
Definition:
Table of codes that specify the modifying or qualifying description(s) about the specimen source site.  No suggested values.


Code: 0543
Display: Specimen Collection Site
Definition:
Table of codes that specify the modifying or qualifying description(s) about the specimen collection site.  This field differs from Specimen Source Site in those cases where the source site must be approached via a particular site (e.g., anatomic location). For example, in the case where a liver biopsy is obtained via a percutaneous needle, the collection site would be the point of entry of the needle. For venous blood collected from the left radial vein, the collection site could be “antecubital fossa”.  No suggested values.


Code: 0544
Display: Container Condition
Definition:
HL7-defined table of codes used to specify at each receipt the status of the container in which the specimen is shipped in chain of custody cases where specimens are moved from lab to lab.  If the container is compromised in any way (seal broken, container cracked or leaking, etc.), then this status needs to be recorded for legal reasons.


Code: 0545
Display: Language Translated To
Definition:
Table of codes that specify the language to which the consent material must be translated.  Used in the Consent (CON) segment in Version 2 messaging.  Table is no longer published as part of the released Standard after version 2.5.1.


Code: 0547
Display: Jurisdictional Breadth
Definition:
Table of codes used to specify the breadth/extent of the jurisdiction where the qualification is valid.


Code: 0549
Display: NDC Codes
Definition:
Table of codes that specify the National Drug Codes (NDC) that are required by the Health Insurance Portability and Accountability Act (HIPAA) for electronic claims for pharmacy charges.  No suggested values.


Code: 0552
Display: Advanced Beneficiary Notice Override Reason
Definition:
Table of codes that specify the reason the patient did not sign an Advanced Beneficiary Notice.  No suggested values.


Code: 0562
Display: Processing Consideration Codes
Definition:
Table of codes used to specify special processing requested of Payer for this Product/Service Line Item (e.g., hold until paper supporting documentation is received by Payer).


Code: 0564
Display: Adjustment Category Code
Definition:
Table of codes used to specify the category of adjustment and is used to assist in determining which table is used for Adjustment Reason.


Code: 0625
Display: Item Status Codes
Definition:
Table of codes specifying the state of an inventory item within the context of an inventory location.


Code: 0634
Display: Item Importance Codes
Definition:
Table of codes that denote a level or importance of an inventory item within the context of an inventory location.


Code: 0651
Display: Labor Calculation Type
Definition:
Table of codes specifying the method used to calculate employee labor and measure employee productivity.


Code: 0659
Display: Lot Control
Definition:
Table of codes specifying whether the sterilization load for a device is built in the sub-sterile area adjacent to an Operating Room or the Central Processing Department.


Code: 0669
Display: Load Status
Definition:
Table of codes specifying the status of the information provided in a device sterilization or decontamination cycle.


Code: 0702
Display: Cycle Type
Definition:
Table of codes specifying the type of cycle that is being executed.  A cycle type is a specific sterilization method used for a specific type of supply item.


Code: 0719
Display: Access Restriction Reason Code
Definition:
Table of codes specifying the reason for the restricted access.  Note these codes are maintained within HL7, but outside of Version 2.


Code: 0728
Display: CCL Value
Definition:
Table of codes specifying the clinical complexity level (CCL) value for the determined diagnosis related group (DRG) for this diagnosis.  US Realm.


Code: 0731
Display: DRG Diagnosis Determination Status
Definition:
HL7-defined table of codes specifying the status of a diagnosis for a diagnosis related group (DRG) determination. US Realm.


Code: 0739
Display: DRG Status Patient
Definition:
Table of codes specifying whether the length of stay is normal or respectively shorter or longer than normal.


Code: 0742
Display: DRG Status Financial Calculation
Definition:
Table of codes specifying the status of the diagnosis related group (DRG) calculation regarding the financial aspects. US Realm.


Code: 0749
Display: DRG Grouping Status
Definition:
Table of codes specifying the status of the use of the gender information for diagnosis related group (DRG) determination. US Realm.


Code: 0755
Display: Status Weight At Birth
Definition:
Table of codes specifying the status of the use of the weight at birth for diagnosis related group (DRG) determination.  US Realm.


Code: 0757
Display: DRG Status Respiration Minutes
Definition:
Table of codes specifying the status of the use of the respiration minutes information for diagnosis related group (DRG) determination.  US Realm.


Code: 0759
Display: Status Admission
Definition:
Table of codes specifying the admission status for the diagnosis related group (DRG) determination. US Realm.


Code: 0761
Display: DRG Procedure Determination Status
Definition:
Table of codes specifying the status of the use of this particular procedure for the diagnosis related group (DRG) determination.  US Realm.


Code: 0763
Display: DRG Procedure Relevance
Definition:
Table of codes specifying the relevance of this particular procedure for the diagnosis related group (DRG) determination. US Realm.


Code: 0776
Display: Item Status
Definition:
Table of codes specifying the status (useful for reporting and item usage purposes) that applies to an item.


Code: 0778
Display: Item Type
Definition:
Table of codes specifying a classification of material items into like groups as defined and utilized within an operating room setting for charting procedures.


Code: 0790
Display: Approving Regulatory Agency
Definition:
Table of codes specifying the regulatory agency by which the item has been approved, such as the FDA or AMA.


Code: 0793
Display: Ruling Act
Definition:
Table of codes specifying an act containing a rule that the item is legally required to be included in notification reporting.


Code: 0806
Display: Sterilization Type
Definition:
Table of codes specifying the type of sterilization used for sterilizing the inventory supply item in the ITM segment.


Code: 0809
Display: Maintenance Cycle
Definition:
Table of codes specifying the maintenance cycle used for the inventory supply item, such as the number of times to sharpen after five uses.  No suggested values.


Code: 0811
Display: Maintenance Type
Definition:
Table of codes specifying the type of maintenance performed on the inventory supply item.  This is different than the maintenance cycle in the sense that it can describe the number of maintenance cycles that can be performed before disposing of the inventory supply item.  No suggested values.


Code: 0818
Display: Package
Definition:
Table of codes specifying the packaging unit in which this inventory supply item can be ordered or issued when purchased from the vendor in the related vendor segment.


Code: 0865
Display: Referral Documentation Completion Status
Definition:
Table of codes specifying to the receiving provider that the clinical history in the message is incomplete and that more will follow.  No suggested values.


Code: 0880
Display: Product/Service Code Modifier
Definition:
Table of codes specifying additional optional modifier(s) for the Product/Service Code (e.g., after hours - evening, after hours - weekend).  No suggested values.


Code: 0881
Display: Role Executing Physician
Definition:
Table of codes specifying the account role of the physician, for example, only billing for the professional part, the technical part or both.


Code: 0895
Display: Present On Admission (POA) Indicator
Definition:
Table of codes specifying the present on admission indicator for this particular diagnosis. US reimbursement formulas for some states and Medicare have mandated that each diagnosis code be flagged as to whether it was present on admission or not.


Code: 0912
Display: Participation
Definition:
HL7-defined table of codes that represent functional involvement of a caregiver or member of a care team with an activity being transmitted (e.g., Case Manager, Evaluator, Transcriber, Nurse Care Practitioner, Midwife, Physician Assistant, etc.).


Code: 0913
Display: Monetary Denomination Code
Definition:
Table of codes specifying the denomination in which the quantity is expressed. The values for the denomination component are the three-character codes specified in  ISO-4217 (1.0.4217 iso4217).


Code: 0916
Display: Relevant Clincial Information
Definition:
Table of codes specifying additional clinical information about the patient or specimen to report the supporting and/or suspected diagnosis and clinical findings on requests for interpreted diagnostic studies.


Code: 0919
Display: Exclusive Test
Definition:
HL7-defined table of codes that define if a test should be a specific event with no other tests to be performed with this test, or not, or other special circumstances.


Code: 0920
Display: Preferred Specimen/Attribute Status
Definition:
HL7-defined table of codes that indicate whether a Specimen/Attribute is Preferred or Alternate for collection of a particular specimen.


Code: 0923
Display: Process Interruption
Definition:
HL7-defined table of codes specifying whether the process was interrrupted and whether the needle had been inserted in the donor's arm prior to the interruption.


Code: 0936
Display: Observation Type
Definition:
HL7-defined table of codes specifying types of observations to enable systems to distinguish between observations sent along with an order, versus observations sent as the result to an order.


Code: 0941
Display: Procedure Code
Definition:
Table of codes specifying procedure codes that may impact payer coverage requirements, for example procedure code 1234 is not covered by a payer ABCD or may be covered in conjunction with a specific diagnosis code which can be identifeid in DPS-1 Diagnosis Code. The procedure codes should be drawn from appropriate externally defined procedure codes, for example in the US Realm these include CPT-4 codes defined by the American Medical Association and ICD codes published by CMS.  No suggested values.


Code: 0942
Display: Equipment State Indicator Type Code
Definition:
HL7-defined table of codes that specify the type of measurement of the state of an automated laboratory instrument.


Code: 0943
Display: Transport Destination
Definition:
Table of codes that identify the destination for transport of a specific container.  No suggested values.


Code: 0944
Display: Transport Route
Definition:
Table of codes that identify the route for transport of a specific container.    No suggested values.


Code: 0945
Display: Auto-Dilution Type
Definition:
Vendor-defined codes of the pre‑configured dilution to be applied on the instrument, which can be used instead of a numeric declaration.


Code: 0946
Display: Supplier Type
Definition:
Table of codes specifying the type of supplier that will distribute the supply items associated to a contract number.


Code: 0947
Display: Class of Trade
Definition:
Table of codes specifying the purchasing channel with which the contract is associated  such as Hospital, Retail, etc.  No suggested values.


Code: 0948
Display: Relationship Type
Definition:
HL7-defined table of codes specifying the type of relationship identified by Relationship Instance Identifier (REL-3) that is established between the Source Information Instance (REL-4)  and the Target Information Instance (REL-5).


Code: 0949
Display: Order Control Code Reason
Definition:
HL7-defined table of codes that describe reasons for the chosen order control codes – this table is extensible; while these codes are intended to be generally useful, they were developed to cover situations for replacement orders (ORC-1 = RO) and recommendations for replacement orders (ORC-1 = RP)


Code: 0951
Display: Reason for Study
Definition:
HL7-defined table of codes that provide additional information to the universal service identifier on why a test, study or review was ordered. Current suggested values are in support of the IHE LCC LAB-7 transaction.


Code: 0952
Display: Confidentiality Classification
Definition:
Table of codes that specify the security classification; the codes are non-overlapping n the following  hierarchical order:
 Very Restricted > Restricted > Normal > Moderate > Low > Unrestricted
More information may be found the HL7 Healthcare Privacy and Security Classification System (HCS), Release 1 (see: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=345)
For the list of codes in the table, see the HL7 Webpage rendering.


Code: 0959
Display: Work Classification ODH
Definition:
A patient's employment type as defined by work classification (e.g. paid vs. unpaid, self-employed vs. not self-employed, government vs. private, etc.).For the list of codes in the table, see the FHIR rendering.


Code: 0960
Display: Data Absent Reason
Definition:
Used to specify why the normally expected content of the data element is missing.  Note that this content is maintained in the FHIR product family.


Code: 0965
Display: Contract Type
Definition:
Values describing the scope of contracts, for example Local, Regional and Global.  No suggested values.


Code: 0966
Display: Pricing Tier Level
Definition:
Values the describing the declared level of pricing for a particular product under a contract, usually based on a discount for larger orders under the contract – often assigned numerically, for example: 01 = Tier 1, 02 = Tier 2, 03 = Tier 3
No suggested values.


Code: 0968
Display: Container Material
Definition:
Values describing the material a container is made of or indication that the container may be a virtual type.  No suggested values.


Code: 0969
Display: Container Common Name
Definition:
Codes created by an organization as a shorthand way to express a combination of container attributes.  No suggested values.


Code: 4000
Display: Name/address representation
Definition:
HL7-defined table of codes that provide an indication of the kind of representation provided by a name or address, but does not necessarily specify the character sets used for the data.  It is used to provides hints for a receiver, so it can make choices regarding what it has been sent and what it is capable of displaying.


Code: INTERR
Display: Internal system error
Definition:
An internal software component (database, application, queue mechanism, etc.) has failed, leading to inability to process the message.


Code: NOSTORE
Display: No storage space for message.
Definition:
**Rejection:** The message can't be stored by the receiver due to an unspecified internal application issue. The message was neither processed nor stored by the receiving application.


Code: RTEDEST
Display: Message routing error, destination unreachable.
Definition:
**Error:** The destination of this message is known to the receiving application. Messages have been successfully routed to that destination in the past. The link to the destination application or an intermediate application is unavailable.


Code: RTUDEST
Display: Error: Message routing error, unknown destination.
Definition:
The destination of this message is unknown to the receiving application. The receiving application in the message does not match the application which received the message. The message was neither routed, processed nor stored by the receiving application.


Code: RTWDEST
Display: Message routing warning, destination unreachable.
Definition:
**Warning:** The destination of this message is known to the receiving application. Messages have been successfully routed to that destination in the past. The link to the destination application or an intermediate application is (temporarily) unavailable. The receiving application will forward the message as soon as the destination can be reached again.


Code: SYN105
Display: Required element missing
Definition:
**Description:** Required association or attribute missing in message; or the sequence of the classes is different than required by the standard or one of the conformance profiles identified in the message.


Code: SYN100
Display: Required association missing
Definition:
Required association missing in message; or the sequence of the classes is different than required by the standard or one of the conformance profiles identified in the message.


Code: SYN114
Display: Insufficient repetitions
Definition:
**Description:** The number of repetitions of a group of association or attributes is less than the required minimum for the standard or of one of the conformance profiles or templates identified in the message.


Code: SYN106
Display: Terminology error
Definition:
**Description:** A coded attribute or datatype property violates one of the terminology constraints specified in the standard or one of the conformance profiles or templates declared by the instance.


Code: SYN107
Display: Deprecated code
Definition:
**Description:** A coded attribute is referencing a code that has been deprecated by the owning code system.


Code: SYN108
Display: Number of repetitions exceeds limit
Definition:
**Description:** The number of repetitions of a (group of) association(s) or attribute(s) exceeds the limits of the standard or of one of the conformance profiles or templates identified in the message.


Code: SYN110
Display: Number of association repetitions exceeds limit
Definition:
The number of repetitions of a (group of) association(s) exceeds the limits of the standard or of one of the conformance profiles identified in the message.


Code: SYN112
Display: Number of attribute repetitions exceeds limit
Definition:
The number of repetitions of an attribute exceeds the limits of the standard or of one of the conformance profiles identified in the message.


Code: SYN109
Display: Mandatory element with null value
Definition:
**Description:** An attribute or association identified as mandatory in a specification or declared conformance profile or template has been specified with a null flavor.


Code: SYN111
Display: Value does not match fixed value
Definition:
**Description:** The value of an attribute or property differs from the fixed value asserted in the standard or one of the conformance profiles or templates declared in the message.


Code: SYN113
Display: Formal constraint violation
Definition:
**Description:** A formal constraint asserted in the standard or one of the conformance profiles or templates declared in the message has been violated.


Code: E
Display: Error
Definition:
**Definition:**An issue which has prevented, or will prevent (unless a management is provided for the issue by the sender), the successful processing of an interaction. Response interactions which include an issue which is an Error are a 'rejection', indicating that the request was not successfully processed.

**Example:**Unable to find specified patient.


Code: I
Display: Information
Definition:
**Definition:** The message relates to an issue which has no bearing on the successful processing of the request. Information issues cannot be overridden by specifying a management.

**Example:** A Patient's coverage will expire in 5 days.


Code: W
Display: Warning
Definition:
**Definition:** The message relates to an issue which cannot prevent the successful processing of a request, but which could result in the processing not having the ideal or intended effect. Managing a warning issue is not required for successful processing, but will suppress the warning from being raised.

**Example:**

Unexpected additional repetitions of phone number have been ignored.


Code: AE
Display: Application Acknowledgement Error
Definition:
Receiving application found error in processing message. Sending error response with additional error detail information.


Code: AR
Display: Application Acknowledgement Reject
Definition:
Receiving application failed to process message for reason unrelated to content or format. Original message sender must decide on whether to automatically send message again.


Code: CA
Display: Accept Acknowledgement Commit Accept
Definition:
Receiving message handling service accepts responsibility for passing message onto receiving application.


Code: CE
Display: Accept Acknowledgement Commit Error
Definition:
Receiving message handling service cannot accept message for any other reason (e.g. message sequence number, etc.).


Code: CR
Display: Accept Acknowledgement Commit Reject
Definition:
Receiving message handling service rejects message if interaction identifier, version or processing mode is incompatible with known receiving application role information.


Code: ENTRY
Display: entry
Definition:
This context represents the information acquired and recorded for an observation, a clinical statement such as a portion of the patient's history or an inference or assertion, or an action that might be intended or has actually been performed. This class may represent both the actual data describing the observation, inference, or action, and optionally the details supporting the clinical reasoning process such as a reference to an electronic guideline, decision support system, or other knowledge reference.


Code: ORGANIZER
Display: organizer
Definition:
Organizer of entries. Navigational. No semantic content. Knowledge of the section code is not required to interpret contained observations. Represents a heading in a heading structure, or "organizer 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.


Code: CONTAINER
Display: record container
Definition:
**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.


Code: FOLDER
Display: folder
Definition:
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.


Code: GROUPER
Display: grouper
Definition:
**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.


Code: LLD
Display: left lateral decubitus
Definition:
Lying on the left side.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: PRN
Display: prone
Definition:
Lying with the front or ventral surface downward; lying face down.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: RLD
Display: right lateral decubitus
Definition:
Lying on the right side.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: SFWL
Display: Semi-Fowler's
Definition:
A semi-sitting position in bed with the head of the bed elevated approximately 45 degrees.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: SIT
Display: sitting
Definition:
Resting the body on the buttocks, typically with upper torso erect or semi erect.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: STN
Display: standing
Definition:
To be stationary, upright, vertical, on one's legs.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: SUP
Display: supine
Definition:
***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: _SubjectBodyPosition
Display: subject body position
Definition:
Contains codes for defining the observed, physical position of a subject, such as during an observation, assessment, collection of a specimen, etc. ECG waveforms and vital signs, such as blood pressure, are two examples where a general, observed position typically needs to be noted.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: _ActClassRecordOrganizer
Display: record organizer
Definition:
Used to group a set of acts sharing a common context. Organizer structures can nest within other context structures - such as where a document is contained within a folder, or a folder is contained within an EHR extract.


Code: CONC
Display: concern
Definition:
**Definition:** A worry that tends to persist over time and has as its subject a state or process. The subject of the worry has the potential to require intervention or management.

**Examples:** an observation result, procedure, substance administration, equipment repair status, device recall status, a health risk, a financial risk, public health risk, pregnancy, health maintenance, allergy, and acute or chronic illness.


Code: EXPOS
Display: exposure
Definition:
An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity.

*Examples:* The following examples are provided to indicate what interactions are considered exposures rather than other types of Acts:

 *  A patient accidentally receives three times the recommended dose of their medication due to a dosing error.
    
     *  This is a substance administration. Public health and/or safety authorities may also be interested in documenting this with an associated exposure.
 *  A patient accidentally is dispensed an incorrect medicine (e.g., clomiphene instead of clomipramine). They have taken several doses before the mistake is detected. They are therefore "exposed" to a medicine that there was no therapeutic indication for them to receive.
    
     *  There are several substance administrations in this example. Public health and/or safety authorities may also be interested in documenting this with associated exposures.
 *  In a busy medical ward, a patient is receiving chemotherapy for a lymphoma. Unfortunately, the IV infusion bag containing the medicine splits, spraying cytotoxic medication over the patient being treated and the patient in the adjacent bed.
    
     *  There are three substance administrations in this example. The first is the intended one (IV infusion) with its associated (implicit) exposure. There is an incident with an associated substance administration to the same patient involving the medication sprayed over the patient as well as an associated exposure. Additionally, the incident includes a substance administration involving the spraying of medication on the adjacent patient, also with an associated exposure.
 *  A patient who is a refugee from a war-torn African nation arrives in a busy inner city A&E department suffering from a cough with bloody sputum. Not understanding the registration and triage process, they sit in the waiting room for several hours before it is noticed that they have not booked in. As soon as they are being processed, it is suspected that they are suffering from TB. Vulnerable (immunosuppressed) patients who were sharing the waiting room with this patient may have been exposed to the tubercule bacillus, and must be traced for investigation.
    
     *  This is an exposure (or possibly multiple exposures) in the waiting room involving the refugee and everyone else in the waiting room during the period. There might also be a number of known or presumed substance administrations (coughing) via several possible routes. The substance administrations are only hypotheses until confirmed by further testing.
 *  A patient who has received an elective total hip replacement procedure suffers a prolonged stay in hospital, due to contracting an MRSA infection in the surgical wound site after the surgery.
    
     *  This is an exposure to MRSA. Although there was some sort of substance administration, it's possible the exact mechanism for introduction of the MRSA into the wound will not be identified.
 *  Routine maintenance of the X-ray machines at a local hospital reveals a serious breach of the shielding on one of the machines. Patients who have undergone investigations using that machine in the last month are likely to have been exposed to significantly higher doses of X-rays than was intended, and must be tracked for possible adverse effects.
    
     *  There has been an exposure of each patient who used the machine in the past 30 days. Some patients may have had substance administrations.
 *  A new member of staff is employed in the laundry processing room of a small cottage hospital, and a misreading of the instructions for adding detergents results in fifty times the usual concentration of cleaning materials being added to a batch of hospital bedding. As a result, several patients have been exposed to very high levels of detergents still present in the "clean" bedding, and have experienced dermatological reactions to this.
    
     *  There has been an incident with multiple exposures to several patients. Although there are substance administrations involving the application of the detergent to the skin of the patients, it is expected that the substance administrations would not be directly documented.
 *  Seven patients who are residents in a health care facility for the elderly mentally ill have developed respiratory problems. After several months of various tests having been performed and various medications prescribed to these patients, the problem is traced to their being "sensitive" to a new fungicide used in the wall plaster of the ward where these patients reside.
    
     *  The patients have been continuously exposed to the fungicide. Although there have been continuous substance administrations (via breathing) this would not normally be documented as a substance administration.
 *  A patient with osteoarthritis of the knees is treated symptomatically using analgesia, paracetamol (acetaminophen) 1g up to four times a day for pain relief. His GP does not realize that the patient has, 20 years previously (while at college) had severe alcohol addiction problems, and now, although this is completely under control, his liver has suffered significantly, leaving him more sensitive to hepatic toxicity from paracetamol use. Later that year, the patient returns with a noticeable level of jaundice. Paracetamol is immediately withdrawn and alternative solutions for the knee pain are sought. The jaundice gradually subsides with conservative management, but referral to the gastroenterologist is required for advice and monitoring.
    
     *  There is a substance administration with an associated exposure. The exposure component is based on the relative toxic level of the substance to a patient with a compromised liver function.
 *  A patient goes to their GP complaining of abdominal pain, having been discharged from the local hospital ten days' previously after an emergency appendectomy. The GP can find nothing particularly amiss, and presumes it is post operative surgical pain that will resolve. The patient returns a fortnight later, when the GP prescribes further analgesia, but does decide to request an outpatient surgical follow-up appointment. At this post-surgical outpatient review, the registrar decides to order an ultrasound, which, when performed three weeks later, shows a small faint inexplicable mass. A laparoscopy is then performed, as a day case procedure, and a piece of a surgical swab is removed from the patient's abdominal cavity. Thankfully, a full recovery then takes place.
    
     *  This is a procedural sequelae. There may be an Incident recorded for this also.
 *  A patient is slightly late for a regular pacemaker battery check in the Cardiology department of the local hospital. They are hurrying down the second floor corridor. A sudden summer squall has recently passed over the area, and rain has come in through an open corridor window leaving a small puddle on the corridor floor. In their haste, the patient slips in the puddle and falls so badly that they have to be taken to the A&E department, where it is discovered on investigation they have slightly torn the cruciate ligament in their left knee.
    
     *  This is not an exposure. There has been an incident.

*Usage Notes:* This class deals only with opportunity and not the outcome of the exposure; i.e. not all exposed parties will necessarily experience actual harm or benefit.

Exposure differs from Substance Administration by the absence of the participation of a performer in the act.

The following participations SHOULD be used with the following participations to distinguish the specific entities:

 *  The exposed entity participates via the "exposure target" (EXPTRGT) participation.
 *  An entity that has carried the agent transmitted in the exposure participates via the "exposure source" (EXSRC) participation. For example:
    
     *  a person or animal who carried an infectious disease and interacts (EXSRC) with another person or animal (EXPTRGT) transmitting the disease agent;
     *  a place or other environment (EXSRC) and a person or animal (EXPTRGT) who is exposed in the presence of this environment.
 *  When it is unknown whether a participating entity is the source of the agent (EXSRC) or the target of the transmission (EXPTRGT), the "exposure participant" (EXPART) is used.
 *  The physical (including energy), chemical or biological substance which is participating in the exposure uses the "exposure agent" (EXPAGNT) participation. There are at least three scenarios:
    
    1.  the player of the Role that participates as EXPAGNT is the chemical or biological substance mixed or carried by the scoper-entity of the Role (e.g., ingredient role); or
    2.  the player of the Role that participates as EXPAGNT is a mixture known to contain the chemical, radiological or biological substance of interest; or
    3.  the player of the Role that participates as a EXPAGNT is known to carry the agent (i.e., the player is a fomite, vector, etc.).

The Exposure.statusCode attribute should be interpreted as the state of the Exposure business object (e.g., active, aborted, completed) and not the clinical status of the exposure (e.g., probable, confirmed). The clinical status of the exposure should be associated with the exposure via a subject observation.

*Design Comment:* The usage notes require a clear criterion for determining whether an act is an exposure or substance administration-deleterious potential, uncertainty of actual transmission, or otherwise. SBADM states that the criterion is the presence of a performer-but there are examples above that call this criterion into question (e.g., the first one, concerning a dosing error).


Code: REG
Display: registration
Definition:
Represents the act of maintaining information about the registration of its associated registered subject. The subject can be either an Act or a Role, and includes subjects such as lab exam definitions, drug protocol definitions, prescriptions, persons, patients, practitioners, and equipment.

The registration may have a unique identifier - separate from the unique identification of the subject - as well as a core set of related participations and act relationships that characterize the registration event and aid in the disposition of the subject information by a receiving system.


Code: STC
Display: state transition control
Definition:
**Description:** Sender transmits a status change pertaining to the focal act of the payload. This status of the focal act is the final state of the state transition. This can be either a request or an event, according to the mood of the control act.


Code: DOC
Display: document
Definition:
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.


Code: HCASE
Display: public health case
Definition:
A public health case is a Concern about an observation or event that has a specific significance for public health. The creation of a PublicHealthCase initiates the tracking of the object of concern. The decision to track is related to but somewhat independent of the underlying event or observation.

**UsageNotes:** Typically a Public Health Case 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.

A public health case definition (Act.moodCode = "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. 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.


Code: OUTBR
Display: outbreak
Definition:
An Outbreak is a concern resulting from a series of public health cases.

**UsageNotes:** 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. The effectiveTime attribute is used to convey the relevant dates for the case. An outbreak definition (Act.moodCode = "definition" includes the criteria for the number, types and occurrence pattern of cases necessary to declare an outbreak and to judge the severity of an outbreak.


Code: DOCCLIN
Display: clinical document
Definition:
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.


Code: CLUSTER
Display: Cluster
Definition:
**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.


Code: BATTERY
Display: battery
Definition:
**Definition:** An observation that is composed of a set of observations. These observations typically have a logical or practical grouping for generally accepted clinical or functional purposes, such as observations that are run together because of automation. A battery can define required and optional component observations and, in some cases, will define complex rules that determine whether or not a particular observation is made. BATTERY is a constraint on the Observation class in that it is understood to always be composed of component observations.

**UsageNotes:** The focus in a BATTERY is that it is composed of individual observations. In request (RQO) mood, a battery is a request to perform the component observations. In event (EVN) mood a battery is a reporting of associated set of observation events. In definition mood a battery is the definition of the associated set of observations.

**Examples:** Vital signs, Full blood count, Chemistry panel.


Code: CNOD
Display: Condition Node
Definition:
An instance of Observation of a Condition at a point in time that includes any Observations or Procedures associated with that Condition as well as links to previous instances of Condition Node for the same Condition

***Deprecation Comment:*** This concept has been deprecated because an alternative structure for tracking the evolution of a problem has been presented and adopted by the Care Provision Work Group.


Code: DIET
Display: diet
Definition:
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.typeCode="product". Medically relevant diet types may be communicated in the Diet.code attribute using domain ActDietCode, however, the detail of the food supplied and the various combinations of dishes should be communicated as Material instances.

**Deprecation Note**

**Class:** Use either the Supply class (if dealing with what should be given to the patient) or SubstanceAdministration class (if dealing with what the patient should consume)

**energyQuantity:** This quantity can be conveyed by using a Content relationship with a quantity attribute expressing the calories

**carbohydrateQuantity:**This quantity can be conveyed using a Content relationship to an Entity with a code of carbohydrate and a quantity attribute on the content relationship.


Code: RTRD
Display: reverse trendelenburg
Definition:
Lying on the back, on an inclined plane, typically about 30-45 degrees with head raised and feet lowered.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: TRD
Display: trendelenburg
Definition:
Lying on the back, on an inclined plane, typically about 30-45 degrees, with head lowered and feet raised.

***Deprecation Comment:*** This concept has been deprecated because it does not describe a type of Act (as it should in the ActClass code system), but rather encodes the result or value of an observation. The same code has been added to the ObservationValue code system.


Code: _ActInformationAccessCode
Display: ActInformationAccessCode
Definition:
**Description:** The type of health information to which the subject of the information or the subject's delegate consents or dissents.


Code: _ActInformationAccessContextCode
Display: ActInformationAccessContextCode
Definition:
Concepts conveying the context in which authorization given under jurisdictional law, by organizational policy, or by a patient consent directive permits the collection, access, use or disclosure of specified patient health information.


Code: _ActPolicyType
Display: ActPolicyType
Definition:
A mandate, regulation, obligation, principle, requirement, rule, or expectation of how an entity is to conduct itself or execute an activity, which may be dictated and enforced by an authority of competent jurisdiction.


Code: _ActSubstanceAdministrationCode
Display: ActSubstanceAdministrationCode
Definition:
**Description:** Describes the type of substance administration being performed. This should not be used to carry codes for identification of products. Use an associated role or entity to carry such information.


Code: _ActTaskCode
Display: ActTaskCode
Definition:
**Description:** A task or action that a user may perform in a clinical information system (e.g., medication order entry, laboratory test results review, problem list entry).


Code: DRUGPRG
Display: drug program
Definition:
**Definition:** A public or government health program that administers and funds coverage for prescription drugs to assist program eligible who meet financial and health status criteria.


Code: F
Display: final
Definition:
**Description:**Indicates that a result is complete. No further results are to come. This maps to the 'complete' state in the observation result status code.


Code: PRLMN
Display: preliminary
Definition:
**Description:**Indicates that a result is incomplete. There are further results to come. This maps to the 'active' state in the observation result status code.


Code: SECOBS
Display: SecurityObservationType
Definition:
An observation identifying security metadata about an IT resource (data, information object, service, or system capability), which may be used to make access control decisions. Security metadata are used to name security labels.

*Rationale:* According to ISO/TS 22600-3:2009(E) A.9.1.7 SECURITY LABEL MATCHING, Security label matching compares the initiator's clearance to the target's security label. All of the following must be true for authorization to be granted:

 *  The security policy identifiers shall be identical
 *  The classification level of the initiator shall be greater than or equal to that of the target (that is, there shall be at least one value in the classification list of the clearance greater than or equal to the classification of the target), and
 *  For each security category in the target label, there shall be a security category of the same type in the initiator's clearance and the initiator's classification level shall dominate that of the target.

**Examples:** SecurityObservationType security label fields include:

 *  Confidentiality classification
 *  Compartment category
 *  Sensitivity category
 *  Security mechanisms used to ensure data integrity or to perform authorized data transformation
 *  Indicators of an IT resource completeness, veracity, reliability, trustworthiness, or provenance.

*Usage Note:* SecurityObservationType codes designate security label field types, which are valued with an applicable SecurityObservationValue code as the "security label tag".


Code: SUBSIDFFS
Display: subsidized fee for service program
Definition:
**Definition:** A government health program that provides coverage on a fee for service basis for health services to persons meeting eligibility criteria such as income, location of residence, access to other coverages, health condition, and age, the cost of which is to some extent subsidized by public funds.

*Discussion:* The structure and business processes for underwriting and administering a subsidized fee for service program is further specified by the Underwriter and Payer Role.class and Role.code.


Code: WRKCOMP
Display: (workers compensation program
Definition:
**Definition:** Government mandated program providing coverage, disability income, and vocational rehabilitation for injuries sustained in the work place or in the course of employment. Employers may either self-fund the program, purchase commercial coverage, or pay a premium to a government entity that administers the program. Employees may be required to pay premiums toward the cost of coverage as well.


Code: _ActAdjudicationInformationCode
Display: ActAdjudicationInformationCode
Definition:
Explanatory codes that provide information derived by an Adjudicator during the course of adjudicating an invoice.

Codes from this domain are purely informational and do not materially affect the adjudicated invoice. That is, these codes do not impact or explain financial adjustments to an invoice. A companion domain (ActAdjudicationReasonCode) includes reasons which have a financial impact on an Invoice (claim).

Example adjudication information code is 54540 - Patient has reached Plan Maximum for current year.


Code: _ActIdentityDocumentCode
Display: ActIdentityDocumentCode
Definition:
Code identifying the type of identification document (e.g. passport, drivers license)

**Implementation Note:**The proposal called for a domain, but a code was also provided. When codes are available for the value set the code IDENTDOC (identity document) will be used as the headcode for the specializable value set.


Code: _ActSecurityObjectCode
Display: ActSecurityObjectCode
Definition:
**Description:**An access control object used to manage permissions and capabilities of users within information systems. (See HL7 RBAC specification fo examples of thes objects.)


Code: _CPT4
Display: CPT4
Definition:
**Description:**Physicians Current Procedural Terminology (CPT) Manual is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. Available for the AMA at the address listed for CPT above. These codes are found in Appendix A of CPT 2000 Standard Edition. (CPT 2000 Standard Edition, American Medical Association, Chicago, IL).


Code: _ObservationActAgeGroupType
Display: ObservationActAgeGroupType
Definition:
**Description:**To allow queries to specify useful information about the age of the patient without disclosing possible protected health information.


Code: ACCTRECEIVABLE
Display: account receivable
Definition:
An account for collecting charges, reversals, adjustments and payments, including deductibles, copayments, coinsurance (financial transactions) credited or debited to the account receivable account for a patient's encounter.


Code: CC
Display: credit card
Definition:
**Description:** Types of advance payment to be made on a plastic card usually issued by a financial institution used of purchasing services and/or products.


Code: AR
Display: adjudicated as refused
Definition:
The invoice element has passed through the adjudication process but payment is refused due to one or more reasons.

Includes items such as patient not covered, or invoice element is not constructed according to payer rules (e.g. 'invoice submitted too late').

If one invoice element line item in the invoice element structure is rejected, the remaining line items may not be adjudicated and the complete group is treated as rejected.

A refused invoice element can be forwarded to the next payer (for Coordination of Benefits) or modified and resubmitted to refusing payer.

Invoice element cannot be reversed (nullified) as there is nothing to reverse.

Recommend that the invoice element is not saved for DUR (Drug Utilization Reporting).


Code: AS
Display: adjudicated as submitted
Definition:
The invoice element was/will be paid exactly as submitted, without financial adjustment(s).

If the dollar amount stays the same, but the billing codes have been amended or financial adjustments have been applied through the adjudication process, the invoice element is treated as "Adjudicated with Adjustment".

If information items are included in the adjudication results that do not affect the monetary amounts paid, then this is still Adjudicated as Submitted (e.g. 'reached Plan Maximum on this Claim').

Invoice element can be reversed (nullified).

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).


Code: FORM
Display: Print on Form
Definition:
The adjudication result associated is to be printed on the specified form, which is then provided to the covered party.


Code: SUPPRESSED
Display: record suppressed
Definition:
**Description:** One or more records in the query response have been suppressed due to consent or privacy restrictions.


Code: KEY204
Display: Unknown key identifier
Definition:
The ID of the patient, order, etc., was not found. Used for transactions other than additions, e.g. transfer of a non-existent patient.


Code: KEY205
Display: Duplicate key identifier
Definition:
The ID of the patient, order, etc., already exists. Used in response to addition transactions (Admit, New Order, etc.).


Code: KEY206
Display: non-matching identification
Definition:
**Description:** Metadata associated with the identification (e.g. name or gender) does not match the identification being verified.


Code: HCPCSA
Display: HCPCS Level II and Carrier-assigned
Definition:
**Description:**HCPCS Level II (HCFA-assigned) and Carrier-assigned (Level III) modifiers are reported in Appendix A of CPT 2000 Standard Edition and in the Medicare Bulletin.


Code: _ActMedicalBillableServiceCode
Display: ActMedicalBillableServiceCode
Definition:
**Definition:** An identifying code for billable medical services, as opposed to codes for similar services to identify them for clinical purposes.


Code: _ActNonMedicalBillableServiceCode
Display: ActNonMedicalBillableServiceCode
Definition:
**Definition:** An identifying code for billable services that are not medical procedures, such as social services or governmental program services.

**Example:** Building a wheelchair ramp, help with groceries, giving someone a ride, etc.


Code: BLK
Display: block funding
Definition:
A billing arrangement where a Provider charges a lump sum to provide a prescribed group (volume) of services to a single patient which occur over a period of time. Services included in the block may vary.

This billing arrangement is also known as Program of Care for some specific Payors and Program Fees for other Payors.


Code: CAP
Display: capitation funding
Definition:
A billing arrangement where the payment made to a Provider is determined by analyzing one or more demographic attributes about the persons/patients who are enrolled with the Provider (in their practice).


Code: CONTF
Display: contract funding
Definition:
A billing arrangement where a Provider charges a lump sum to provide a particular volume of one or more interventions/procedures or groups of interventions/procedures.


Code: FINBILL
Display: financial
Definition:
A billing arrangement where a Provider charges for non-clinical items. This includes interest in arrears, mileage, etc. Clinical content is not included in Invoices submitted with this type of billing arrangement.


Code: ROST
Display: roster funding
Definition:
A billing arrangement where funding is based on a list of individuals registered as patients of the Provider.


Code: SESS
Display: sessional funding
Definition:
A billing arrangement where a Provider charges a sum to provide a group (volume) of interventions/procedures to one or more patients within a defined period of time, typically on the same date. Interventions/procedures included in the session may vary.


Code: FFS
Display: fee for service
Definition:
A billing arrangement where a Provider charges a separate fee for each intervention/procedure/event or product.

Fee for Service is used when an individual intervention/procedure/event is used for billing purposes. In other words, fees are associated with the intervention/procedure/event. For example, a specific CCI (Canadian Classification of Interventions) code has an associated fee and is used for billing purposes.


Code: ROIFS
Display: fully specified ROI
Definition:
A fully specified bounded Region of Interest (ROI) delineates a ROI in which only those dimensions participate that are specified by boundary criteria, whereas all other dimensions are excluded. For example a ROI to mark an episode of "ST elevation" in a subset of the EKG leads V2, V3, and V4 would include 4 boundaries, one each for time, V2, V3, and V4.


Code: ROIPS
Display: partially specified ROI
Definition:
A partially specified bounded Region of Interest (ROI) specifies a ROI in which at least all values in the dimensions specified by the boundary criteria participate. For example, if an episode of ventricular fibrillations (VFib) is observed, it usually doesn't make sense to exclude any EKG leads from the observation and the partially specified ROI would contain only one boundary for time indicating the time interval where VFib was observed.


Code: _ActDecision
Display: _ActDecision
Definition:
Specifies the type of agreement between one or more grantor and grantee in which rights and obligations related to one or more shared items of interest are allocated.

*Usage Note:* Such agreements may be considered "consent directives" or "contracts" depending on the context, and are considered closely related or synonymous from a legal perspective.

**Examples:** 

 *  Healthcare Privacy Consent Directive permitting or restricting in whole or part the collection, access, use, and disclosure of health information, and any associated handling caveats.
 *  Healthcare Medical Consent Directive to receive medical procedures after being informed of risks and benefits, thereby reducing the grantee's liability.
 *  Research Informed Consent for participation in clinical trials and disclosure of health information after being informed of risks and benefits, thereby reducing the grantee's liability.
 *  Substitute decision maker delegation in which the grantee assumes responsibility to act on behalf of the grantor.
 *  Contracts in which the agreement requires assent/dissent by the grantor of terms offered by a grantee, a consumer opts out of an "award" system for use of a retailer's marketing or credit card vendor's point collection cards in exchange for allowing purchase tracking and profiling.
 *  A mobile device or App privacy policy and terms of service to which a user must agree in whole or in part in order to utilize the service.
 *  Agreements between a client and an authorization server or between an authorization server and a resource operator and/or resource owner permitting or restricting e.g., collection, access, use, and disclosure of information, and any associated handling caveats.


Code: _ActPrivacyConsentDirective
Display: _ActPrivacyConsentDirective
Definition:
Specifies types of consent directives governing the collection, access, use, or disclosure of personal information, including de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, which may be used to identify an individual.


Code: EMRGONLY
Display: emergency only
Definition:
Privacy consent directive restricting or prohibiting access, use, or disclosure of personal information, including de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, which may be used to identify an individual in a registry or repository for all purposes except for emergency treatment generally, which may include treatment during a disaster, a threat, in an emergency department and for break the glass purposes of use as specified by applicable domain policy.

*Usage Note:* To specify the scope of an "EMRGONLY" consent directive within a policy domain, use one or more of the following Purpose of Use codes in the ActReason code system OID: 2.16.840.1.113883.5.8.

 *  ETREAT (Emergency Treatment): To perform one or more operations on information for provision of immediately needed health care for an emergent condition.
 *  BTG (break the glass): To perform policy override operations on information for provision of immediately needed health care for an emergent condition affecting potential harm, death or patient safety by end users who are not provisioned for this purpose of use. Includes override of organizational provisioning policies and may include override of subject of care consent directive restricting access.
 *  ERTREAT (emergency room treatment): To perform one or more operations on information for provision of immediately needed health care for an emergent condition in an emergency room or similar emergent care context by end users provisioned for this purpose, which does not constitute as policy override such as in a "Break the Glass" purpose of use.
 *  THREAT (threat): To perform one or more operations on information used to prevent injury or disease to living subjects who may be the target of violence.
 *  DISASTER (disaster): To perform one or more operations on information used for provision of immediately needed health care to a population of living subjects located in a disaster zone.

Map: An "emergency only" consent directive maps to ISO/TS 17975:2015(E) 5.13 Exceptional access


Code: GRANTORCHOICE
Display: grantor choice
Definition:
A grantor's terms of agreement to which a grantee may assent or dissent, and which may include an opportunity for a grantee to request restrictions or extensions.

*Comment:* A grantor typically is able to stipulate preferred terms of agreement when the grantor has control over the topic of the agreement, which a grantee must accept in full or may be offered an opportunity to extend or restrict certain terms.

*Usage Note:* If the grantor's term of agreement must be accepted in full, then this is considered "basic consent". If a grantee is offered an opportunity to extend or restrict certain terms, then the agreement is considered "granular consent".

**Examples:** 

 *  Healthcare: A PHR account holder \[grantor\] may require any PHR user \[grantee\] to accept the terms of agreement in full, or may permit a PHR user to extend or restrict terms selected by the account holder or requested by the PHR user.
 *  Non-healthcare: The owner of a resource server \[grantor\] may require any authorization server \[grantee\] to meet authorization requirements stipulated in the grantor's terms of agreement.


Code: IMPLIED
Display: implied consent
Definition:
A grantor's presumed assent to the grantee's terms of agreement is based on the grantor's behavior, which may result from not expressly assenting to the consent directive offered, or from having no right to assent or dissent offered by the grantee.

*Comment:* Implied or "implicit" consent occurs when the behavior of the grantor is understood by a reasonable person to signal agreement to the grantee's terms.

*Usage Note:* Implied consent with no opportunity to assent or dissent to certain terms is considered "basic consent".

**Examples:** 

 *  Healthcare: A patient schedules an appointment with a provider, and either does not take the opportunity to expressly assent or dissent to the provider's consent directive, does not have an opportunity to do so, as in the case where emergency care is required, or simply behaves as though the patient \[grantor\] agrees to the rights granted to the provider \[grantee\] in an implicit consent directive.
 *  An injured and unconscious patient is deemed to have assented to emergency treatment by those permitted to do so under jurisdictional laws, e.g., Good Samaritan laws.
 *  Non-healthcare: Upon receiving a driver's license, the driver is deemed to have assented without explicitly consenting to undergoing field sobriety tests.
 *  A corporation that does business in a foreign nation is deemed to have deemed to have assented without explicitly consenting to abide by that nation's laws.


Code: IMPLIEDD
Display: implied consent with opportunity to dissent
Definition:
A grantor's presumed assent to the grantee's terms of agreement, which is based on the grantor's behavior, and includes a right to dissent to certain terms.

*Comment:* A grantor assenting to the grantee's terms of agreement may or may not exercise a right to dissent to grantor selected terms or to grantee's selected terms to which a grantor may dissent.

*Usage Note:* Implied or "implicit" consent with an "opportunity to dissent" occurs when the grantor's behavior is understood by a reasonable person to signal assent to the grantee's terms of agreement whether the grantor requests or the grantee approves further restrictions, is considered "granular consent".

**Examples:** 

 *  Healthcare Examples: A healthcare provider deems a patient's assent to disclosure of health information to family members and friends, but offers an opportunity or permits the patient to dissent to such disclosures.
 *  A health information exchanges deems a patient to have assented to disclosure of health information for treatment purposes, but offers the patient an opportunity to dissents to disclosure to particular provider organizations.
 *  Non-healthcare Examples: A bank deems a banking customer's assent to specified collection, access, use, or disclosure of financial information as a requirement of holding a bank account, but provides the user an opportunity to limit third-party collection, access, use or disclosure of that information for marketing purposes.


Code: NOCONSENT
Display: no consent
Definition:
No notification or opportunity is provided for a grantor to assent or dissent to a grantee's terms of agreement.

*Comment:* A "No Consent" policy scheme provides no opportunity for accommodation of an individual's preferences, and may not comply with Fair Information Practice Principles \[FIPP\] by enabling the data subject to object, access collected information, correct errors, or have accounting of disclosures.

*Usage Note:* The grantee's terms of agreement, may be available to the grantor by reviewing the grantee's privacy policies, but there is no notice by which a grantor is apprised of the policy directly or able to acknowledge.

**Examples:** 

 *  Healthcare: Without notification or an opportunity to assent or dissent, a patient's health information is automatically included in and available (often according to certain rules) through a health information exchange. Note that this differs from implied consent, where the patient is assumed to have consented.
 *  Without notification or an opportunity to assent or dissent, a patient's health information is collected, accessed, used, or disclosed for research, public health, security, fraud prevention, court order, or law enforcement.
 *  Non-healthcare: Without notification or an opportunity to assent or dissent, a consumer's healthcare or non-healthcare internet searches are aggregated for secondary uses such as behavioral tracking and profiling.
 *  Without notification or an opportunity to assent or dissent, a consumer's location and activities in a shopping mall are tracked by RFID tags on purchased items.


Code: NOPP
Display: notice of privacy practices
Definition:
An implied privacy consent directive or notification, which the data subject may or may not acknowledge. The notification specifies permitted actions, which may include access, use, or disclosure of any and all personal information. The notification specifies the scope of personal information, which may include de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, that may be used to identify an individual in a registry or repository. The notification specifies the purposes for which personal information may be used such as treatment, payment, operations, research, information exchange, public health, disaster, quality and safety reporting; as required by law including court order, law enforcement, national security, military authorities; and for data analytics, marketing, and profiling.

*Usage Notes:* Map: An "implied" consent directive maps to ISO/TS 17975:2015(E) definition forImplied: Consent to Collect, Use and Disclose personal health information is implied by the actions or inactions of the individual and the circumstances under which it was implied".


Code: OPTIN
Display: opt-in
Definition:
A grantor's assent to the terms of an agreement offered by a grantee without an opportunity for to dissent to any terms.

*Comment:* Acceptance of a grantee's terms pertaining, for example, to permissible activities, purposes of use, handling caveats, expiry date, and revocation policies.

*Usage Note:* Opt-in with no opportunity for a grantor to restrict certain permissions sought by the grantee is considered "basic consent".

**Examples:** 

 *  Healthcare: A patient \[grantor\] signs a provider's \[grantee's\] consent directive form, which lists permissible collection, access, use, or disclosure activities, purposes of use, handling caveats, and revocation policies.
 *  Non-healthcare: An employee \[grantor\] signs an employer's \[grantee's\] non-disclosure and non-compete agreement.


Code: OPTINR
Display: opt-in with restrictions
Definition:
A grantor's assent to the grantee's terms of an agreement with an opportunity for to dissent to certain grantor or grantee selected terms.

*Comment:* A grantor dissenting to the grantee's terms of agreement may or may not exercise a right to assent to grantor's pre-approved restrictions or to grantee's selected terms to which a grantor may dissent.

*Usage Note:* Opt-in with restrictions is considered "granular consent" because the grantor has an opportunity to narrow the permissions sought by the grantee.

**Examples:** 

 *  Healthcare: A patient assent to grantee's consent directive terms for collection, access, use, or disclosure of health information, and dissents to disclosure to certain recipients as allowed by the provider's pre-approved restriction list.
 *  Non-Healthcare: A cell phone user assents to the cell phone's privacy practices and terms of use, but dissents from location tracking by turning off the cell phone's tracking capability.


Code: OPTOUT
Display: op-out
Definition:
A grantor's dissent to the terms of agreement offered by a grantee without an opportunity for to assent to any terms.

*Comment:* Rejection of a grantee's terms of agreement pertaining, for example, to permissible activities, purposes of use, handling caveats, expiry date, and revocation policies.

*Usage Note:* Opt-out with no opportunity for a grantor to permit certain permissions sought by the grantee is considered "basic consent".

**Examples:** 

 *  Healthcare: A patient \[grantor\] declines to sign a provider's \[grantee's\] consent directive form, which lists permissible collection, access, use, or disclosure activities, purposes of use, handling caveats, revocation policies, and consequences of not assenting.
 *  Non-healthcare: An employee \[grantor\] refuses to sign an employer's \[grantee's\] agreement not to join unions or participate in a strike where state law protects employee's collective bargaining rights.
 *  A citizen \[grantor\] refuses to enroll in mandatory government \[grantee\] health insurance based on religious beliefs, which is an exemption.


Code: OPTOUTE
Display: opt-out with exceptions
Definition:
A grantor's dissent to the grantee's terms of agreement except for certain grantor or grantee selected terms.

*Comment:* A rejection of a grantee's terms of agreement while assenting to certain permissions sought by the grantee or requesting approval of additional grantor terms.

*Usage Note:* Opt-out with exceptions is considered a "granular consent" because the grantor has an opportunity to accept certain permissions sought by the grantee or request additional grantor terms, while rejecting other grantee terms.

**Examples:** 

 *  Healthcare: A patient \[grantor\] dissents to a health information exchange consent directive with the exception of disclosure based on a limited "time to live" shared secret \[e.g., a token or password\], which the patient can give to a provider when seeking care.
 *  Non-healthcare: A social media user \[grantor\] dissents from public access to their account, but assents to access to a circle of friends.


Code: ICOL
Display: information collection
Definition:
**Definition:** Consent to have healthcare information collected in an electronic health record. This entails that the information may be used in analysis, modified, updated.


Code: IP
Display: In Position
Definition:
Used by one system to inform another that the container is in position for specimen transfer (e.g., container removal from track, pipetting, etc.).


Code: M
Display: Missing
Definition:
Used by one system to inform another that the container did not arrive at its next expected location.


Code: O
Display: In Process
Definition:
Used by one system to inform another that the specific container is being processed by the equipment. It is useful as a response to a query about Container Status, when the specific step of the process is not relevant.


Code: R
Display: Process Completed
Definition:
Status is used by one system to inform another that the processing has been completed, but the container has not been released from that system.


Code: X
Display: Container Unavailable
Definition:
Used by one system to inform another that the container is no longer available within the scope of the system (e.g., tube broken or discarded).


Code: ENDC
Display: endogenous content
Definition:
A baseline value for the measured test that is inherently contained in the diluent. In the calculation of the actual result for the measured test, this baseline value is normally considered.


Code: AUTH
Display: Authorized
Definition:
Authorization approved and funds have been set aside to pay for specified healthcare service(s) and/or product(s) within defined criteria for the authorization.


Code: NELG
Display: Not Eligible
Definition:
Insurance coverage is not in effect for healthcare service(s) and/or product(s). May optionally include reasons for the ineligibility.


Code: _ActCoveredPartyLimitCode
Display: ActCoveredPartyLimitCode
Definition:
Codes representing the types of covered parties that may receive covered benefits under a policy or program.


Code: COVPRD
Display: coverage period
Definition:
Codes representing the time period during which coverage is available; or financial participation requirements are in effect.


Code: LFEMX
Display: life time maximum
Definition:
**Definition:** Maximum amount paid by payer or covered party; or maximum number of services or products covered under the policy or program during a covered party's lifetime.


Code: PRDMX
Display: period maximum
Definition:
**Definition:** Maximum amount paid by payer or covered party; or maximum number of services/products covered under the policy or program by time period specified by the effective time on the act.


Code: _ActCoveragePartyLimitGroupCode
Display: ActCoveragePartyLimitGroupCode
Definition:
Codes representing the level of coverage provided under the policy or program in terms of the types of entities that may play covered parties based on their personal relationships or employment status.


Code: CACC
Display: certified anatomic pathology and clinical pathology care
Definition:
**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board.


Code: CNEC
Display: certified neurology care
Definition:
**Description:**Scope of responsibility taken on for specialty care as defined by the respective Specialty Board


Code: LGPC
Display: licensed general physician care
Definition:
**Description:**Scope of responsibility taken-on for physician care of a patient as defined by a governmental licensing agency.


Code: AALC
Display: accredited assisted living care
Definition:
**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the respective accreditation agency.


Code: CACS
Display: certified acute coronary syndrome care
Definition:
**Description:**Scope of responsibility taken on by an organization for care of a patient as defined by the disease management certification agency.


Code: _HCPCSAccommodationCode
Display: HCPCSAccommodationCode
Definition:
**Description:**External value set for accommodation types used in the U.S. Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) including modifiers.


Code: AMB
Display: ambulatory
Definition:
A comprehensive term for health care provided in a healthcare facility (e.g. a practitioneraTMs office, clinic setting, or hospital) on a nonresident basis. The term ambulatory usually implies that the patient has come to the location and is not assigned to a bed. Sometimes referred to as an outpatient encounter.


Code: EMER
Display: emergency
Definition:
A patient encounter that takes place at a dedicated healthcare service delivery location where the patient receives immediate evaluation and treatment, provided until the patient can be discharged or responsibility for the patient's care is transferred elsewhere (for example, the patient could be admitted as an inpatient or transferred to another facility.)


Code: FLD
Display: field
Definition:
A patient encounter that takes place both outside a dedicated service delivery location and outside a patient's residence. Example locations might include an accident site and at a supermarket.


Code: IMP
Display: inpatient encounter
Definition:
A patient encounter where a patient is admitted by a hospital or equivalent facility, assigned to a location where patients generally stay at least overnight and provided with room, board, and continuous nursing service.


Code: OBSENC
Display: observation encounter
Definition:
An encounter where the patient usually will start in different encounter, such as one in the emergency department (EMER) but then transition to this type of encounter because they require a significant period of treatment and monitoring to determine whether or not their condition warrants an inpatient admission or discharge. In the majority of cases the decision about admission or discharge will occur within a time period determined by local, regional or national regulation, often between 24 and 48 hours.


Code: PRENC
Display: pre-admission
Definition:
A patient encounter where patient is scheduled or planned to receive service delivery in the future, and the patient is given a pre-admission account number. When the patient comes back for subsequent service, the pre-admission encounter is selected and is encapsulated into the service registration, and a new account number is generated.

*Usage Note:* This is intended to be used in advance of encounter types such as ambulatory, inpatient encounter, virtual, etc.


Code: SS
Display: short stay
Definition:
An encounter where the patient is admitted to a health care facility for a predetermined length of time, usually less than 24 hours.


Code: VR
Display: virtual
Definition:
A patient encounter where the patient and the practitioner(s) are not in the same physical location. Examples include telephone conference, email exchange, robotic surgery, and televideo conference.


Code: CONVEYNC
Display: Common Conveyance Interaction
Definition:
**Description:** An interaction where the exposure participants traveled in/on the same vehicle (not necessarily concurrently, e.g. both are passengers of the same plane, but on different flights of that plane).


Code: HLTHCARE
Display: Health Care Interaction - Not Patient Care
Definition:
**Description:** Exposure participants' interaction occurred during the course of health care delivery or in a health care delivery setting, but did not involve the direct provision of care (e.g. a janitor cleaning a patient's hospital room).


Code: HOMECARE
Display: Care Giver Interaction
Definition:
**Description:** Exposure interaction occurred in context of one providing care for the other, i.e. a babysitter providing care for a child, a home-care aide providing assistance to a paraplegic.


Code: HOSPPTNT
Display: Hospital Patient Interaction
Definition:
**Description:** Exposure participants' interaction occurred when both were patients being treated in the same (acute) health care delivery facility.


Code: HOSPVSTR
Display: Hospital Visitor Interaction
Definition:
**Description:** Exposure participants' interaction occurred when one visited the other who was a patient being treated in a health care delivery facility.


Code: HOUSEHLD
Display: Household Interaction
Definition:
**Description:** Exposure interaction occurred in context of domestic interaction, i.e. both participants reside in the same household.


Code: INMATE
Display: Inmate Interaction
Definition:
**Description:** Exposure participants' interaction occurred in the course of one or both participants being incarcerated at a correctional facility


Code: INTIMATE
Display: Intimate Interaction
Definition:
**Description:** Exposure interaction was intimate, i.e. participants are intimate companions (e.g. spouses, domestic partners).


Code: LTRMCARE
Display: Long Term Care Facility Interaction
Definition:
**Description:** Exposure participants' interaction occurred in the course of one or both participants being resident at a long term care facility (second participant may be a visitor, worker, resident or a physical place or object within the facility).


Code: PLACE
Display: Common Space Interaction
Definition:
**Description:** An interaction where the exposure participants were both present in the same location/place/space.


Code: PTNTCARE
Display: Health Care Interaction - Patient Care
Definition:
**Description:** Exposure participants' interaction occurred during the course of health care delivery by a provider (e.g. a physician treating a patient in her office).


Code: SCHOOL2
Display: School Interaction
Definition:
**Description:** Exposure participants' interaction occurred in an academic setting (e.g., participants are fellow students, or student and teacher).


Code: SOCIAL2
Display: Social/Extended Family Interaction
Definition:
**Description:** An interaction where the exposure participants are social associates or members of the same extended family


Code: SUBSTNCE
Display: Common Substance Interaction
Definition:
**Description:** An interaction where the exposure participants shared or co-used a common substance (e.g. drugs, needles, or common food item).


Code: TRAVINT
Display: Common Travel Interaction
Definition:
**Description:** An interaction where the exposure participants traveled together in/on the same vehicle/trip (e.g. concurrent co-passengers).


Code: CHRG
Display: Standard Charge
Definition:
A type of transaction that represents a charge for a service or product. Expressed in monetary terms.


Code: REV
Display: Standard Charge Reversal
Definition:
A type of transaction that represents a reversal of a previous charge for a service or product. Expressed in monetary terms. It has the opposite effect of a standard charge.


Code: GDPRCD
Display: GDPR Consent Directive
Definition:
A consent directive compliant with the European Union General Data Protection Regulation (GDPR) definition: Consent of the data subject means any freely given, specific, informed and unambiguous indication of the data subject's wishes by which he or she, by a statement or by a clear affirmative action, signifies agreement to the processing of personal data relating to him or her.

Where processing is based on consent, the controller shall be able to demonstrate that the data subject has consented to processing of his or her personal data. If the data subject's consent is given in the context of a written declaration which also concerns other matters, the request for consent shall be presented in a manner which is clearly distinguishable from the other matters, in an intelligible and easily accessible form, using clear and plain language. Any part of such a declaration which constitutes an infringement of this Regulation shall not be binding. The data subject shall have the right to withdraw his or her consent at any time. The withdrawal of consent shall not affect the lawfulness of processing based on consent before its withdrawal. Prior to giving consent, the data subject shall be informed thereof. It shall be as easy to withdraw as to give consent. When assessing whether consent is freely given, utmost account shall be taken of whether, inter alia, the performance of a contract, including the provision of a service, is conditional on consent to the processing of personal data that is not necessary for the performance of that contract. Consent should be given by a clear affirmative act establishing a freely given, specific, informed and unambiguous indication of the data subject's agreement to the processing of personal data relating to him or her, such as by a written statement, including by electronic means, or an oral statement. This could include ticking a box when visiting an internet website, choosing technical settings for information society services or another statement or conduct which clearly indicates in this context the data subject's acceptance of the proposed processing of his or her personal data. Silence, pre-ticked boxes or inactivity should not therefore constitute consent. Consent should cover all processing activities carried out for the same purpose or purposes. When the processing has multiple purposes, consent should be given for all of them. If the data subject's consent is to be given following a request by electronic means, the request must be clear, concise and not unnecessarily disruptive to the use of the service for which it is provided.

*Usage Note:* Article 4.11 GDPR Definitions https://gdpr-info.eu/art-4-gdpr/ 11) 'Consent' of the data subject means any freely given, specific, informed and unambiguous indication of the data subject's wishes by which he or she, by a statement or by a clear affirmative action, signifies agreement to the processing of personal data relating to him or her. Article 7 GDPR Conditions for consent https://gdpr-info.eu/art-7-gdpr Recital 32 Conditions for consent\* https://gdpr-info.eu/recitals/no-32 Recital 42 Burden of proof and requirements for consent\* https://gdpr-info.eu/recitals/no-42/> Recital 43 Freely given consent\* https://gdpr-info.eu/recitals/no-43 GDPR Consent Brief https://gdpr-info.eu/issues/consent/ Art. 4 GDPR Definitions Art. 6 GDPR Lawfulness of processing Art. 7 GDPR Conditions for consent Art. 8 GDPR Conditions applicable to child's consent in relation to information society services Art. 9 GDPR Processing of special categories of personal data Art. 22 GDPR Automated individual decision-making, including profiling Art. 49 GDPR Derogations for specific situations

Relevant GDPR Recitals: (32) Conditions for consent (33) Consent to certain areas of scientific research (38) Special protection of children's personal data (40) Lawfulness of data processing (42) Burden of proof and requirements for consent (43) Freely given consent (50) Further processing of personal data (51) Protecting sensitive personal data (54) Processing of sensitive data in public health sector (71) Profiling (111) Exceptions for certain cases of international transfers (155) Processing in the employment context (161) Consenting to the participation in clinical trials (171) Repeal of Directive 95/46/EC and transitional provisions


Code: GDPRResearchCD
Display: GDPR Research Consent Directive
Definition:
A consent directive that complies with regulatory requirements for a consent directive compliant with the European Union General Data Protection Regulation (GDPR) definition: Consent of the data subject means any freely given, specific, informed and unambiguous indication of the data subject's wishes by which he or she, by a statement or by a clear affirmative action, signifies agreement to the processing of personal data relating to him or her.

GDPR research consent directive has the additional caveat that it is often not possible to fully identify the purpose of personal data processing for scientific research purposes at the time of data collection. Therefore, data subjects should be allowed to give their consent to certain areas of scientific research when in keeping with recognized ethical standards for scientific research. Data subjects should have the opportunity to give their consent only to certain areas of research or parts of research projects to the extent allowed by the intended purpose.

*Usage Note:* HL7 Purpose of Use codes include specialize research purposes of use, which could be used to convey a data subject's purpose of use restrictions related to areas of research or parts of research projects. See citations for GDPRResearchCD and below: Recital 33 Consent to certain areas of scientific research https://gdpr-info.eu/recitals/no-33/> Recital 157 Information from registries and scientific research https://gdpr-info.eu/recitals/no-157 Recital 159 Processing for scientific research purposes\* https://gdpr-info.eu/recitals/no-159/


Code: GDPRCONSENT
Display: GDPR Consent
Definition:
Processing of personal data, inclusive of the special categories of data, is lawful only if the data subject has given explicit consent to the processing of his or her personal data, inclusive of the special categories of data, for one or more specific purposes, except where Union or Member State law provide that the prohibition to use the data may not be lifted by the data subject; and for personal data which are manifestly made public by the data subject.

*Usage Note:* The description is based on the following GDPR provisions: Article 6.1.a https://gdpr-info.eu/art-6-gdpr/ 1Processing shall be lawful only if and to the extent that at least one of the following applies: (a) the data subject has given consent to the processing of his or her personal data for one or more specific purposes. Article 9.1, 9.2a., 9.2.e https://gdpr-info.eu/art-9-gdpr/ 1. Processing of personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs, or trade union membership, and the processing of genetic data, biometric data for the purpose of uniquely identifying a natural person, data concerning health or data concerning a natural person's sex life or sexual orientation shall be prohibited. 2. Paragraph 1 shall not apply if one of the following applies: (a) the data subject has given explicit consent to the processing of those personal data for one or more specified purposes, except where Union or Member State law provide that the prohibition referred to in paragraph 1 may not be lifted by the data subject; and (e) processing relates to personal data which are manifestly made public by the data subject.


Code: OIC
Display: opt-in to personal information or effect collection in a registry or repository
Definition:
An expressed privacy consent directive permitting the collection of a some or all personal information, including de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, which may be used to identify an individual in a registry or repository for purposes such as treatment, payment, operations, research, information exchange, public health, data analytics, marketing, and profiling.

*Usage Note:* Useful when a more specific jurisdictional or organizational consent directive policy or form is not specified, available, or known, for example, where an individual wishes to opt-in to collection of some or all of the individual's information by multiple registries and repositories.

Map: An "expressed" consent directive maps to ISO/TS 17975:2015(E) definitions for "Express or Expressed: Consent to Collect, Use and Disclose personal health information is expressly given by the subject of care" and "Opt-in".


Code: OIS
Display: opt-in to personal information or effect sharing via a registry or repository
Definition:
An expressed privacy consent directive permitting access, use, or disclosure of a some or all personal information, including de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, which may be used to identify an individual in a registry or repository for purposes such as treatment, payment, operations, research, information exchange, public health, data analytics, marketing, and profiling.

*Usage Note:* Useful when a more specific jurisdictional or organizational consent directive policy or form is not specified, available, or known, for example, where an individual wishes to opt-in to access, use, or disclosure of some or all of the individual's information by multiple registries and repositories.

Map: An "expressed" consent directive maps to ISO/TS 17975:2015(E) Express or Expressed: Consent to Collect, Use and Disclose personal health information is expressly given by the subject of care and "Opt-in".


Code: OOC
Display: opt-out of personal information or effect collection in a registry or repository
Definition:
An expressed privacy consent directive restricting or prohibiting collection of personal information, including de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, which may be used to identify an individual in a registry or repository for purposes such as treatment, payment, operations, research, information exchange, public health, data analytics, marketing, and profiling.

*Usage Note:* Useful when a more specific jurisdictional or organizational consent directive policy or form is not specified, available, or known, for example, where an individual wishes to opt-out of access, use, or disclosure of some or all of the individual's information by multiple registries and repositories.

Map: An "expressed" opt-out to collection consent directive maps to ISO/TS 17975:2015(E) definitions for "Express or Expressed: Consent to Collect, Use and Disclose personal health information is expressly given by the subject of care" and "Express or Expressed (and Informed) Denial".


Code: OOS
Display: opt-out of personal information or effect sharing via a registry or repository
Definition:
An expressed privacy consent directive restricting or prohibiting access, use, or disclosure of personal information, including de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, which may be used to identify an individual in a registry or repository for purposes such as treatment, payment, operations, research, information exchange, public health, data analytics, marketing, and profiling.

*Usage Note:* Useful when a more specific jurisdictional or organizational consent directive policy or form is not specified, available, or known, for example, where an individual wishes to opt-out of access, use, or disclosure of some or all of the individual's information by multiple registries and repositories.

Map: An "expressed" opt-out to sharing consent directive maps to ISO/TS 17975:2015(E) definitions for "Express or Expressed: Consent to Collect, Use and Disclose personal health information is expressly given by the subject of care" and "Express or Expressed (and Informed) Denial".


Code: DISEASE
Display: disease specific policy
Definition:
**Definition:** A health insurance policy that covers benefits for healthcare services provided for named conditions under the policy, e.g., cancer, diabetes, or HIV-AIDS.


Code: DRUGPOL
Display: drug policy
Definition:
**Definition:** A health insurance policy that covers benefits for prescription drugs, pharmaceuticals, and supplies.


Code: EHCPOL
Display: extended healthcare
Definition:
Private insurance policy that provides coverage in addition to other policies (e.g. in addition to a Public Healthcare insurance policy).


Code: HIP
Display: health insurance plan policy
Definition:
**Definition:** A health insurance policy that covers healthcare benefits by protecting covered parties from medical expenses arising from health conditions, sickness, or accidental injury as well as preventive care. Health insurance policies explicitly exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy.

*Discussion:* Health insurance policies are offered by health insurance plans that typically reimburse providers for covered services on a fee-for-service basis, that is, a fee that is the allowable amount that a provider may charge. This is in contrast to managed care plans, which typically prepay providers a per-member/per-month amount or capitation as reimbursement for all covered services rendered. Health insurance plans include indemnity and healthcare services plans.


Code: HSAPOL
Display: health spending account
Definition:
Insurance policy that provides for an allotment of funds replenished on a periodic (e.g. annual) basis. The use of the funds under this policy is at the discretion of the covered party.


Code: LTC
Display: long term care policy
Definition:
**Definition:** An insurance policy that covers benefits for long-term care services people need when they no longer can care for themselves. This may be due to an accident, disability, prolonged illness or the simple process of aging. Long-term care services assist with activities of daily living including:

 *  Help at home with day-to-day activities, such as cooking, cleaning, bathing and dressing
 *  Care in the community, such as in an adult day care facility
 *  Supervised care provided in an assisted living facility
 *  Skilled care provided in a nursing home


Code: MENTPOL
Display: mental health policy
Definition:
**Definition:** A health insurance policy that covers benefits for mental health services and prescriptions.


Code: POS
Display: point of service policy
Definition:
**Definition:** A policy for a health plan that has features of both an HMO and a FFS plan. Like an HMO, a POS plan encourages the use its HMO network to maintain discounted fees with participating providers, but recognizes that sometimes covered parties want to choose their own provider. The POS plan allows a covered party to use providers who are not part of the HMO network (non-participating providers). However, there is a greater cost associated with choosing these non-network providers. A covered party will usually pay deductibles and coinsurances that are substantially higher than the payments when he or she uses a plan provider. Use of non-participating providers often requires the covered party to pay the provider directly and then to file a claim for reimbursement, like in an FFS plan.


Code: VISPOL
Display: vision care policy
Definition:
**Definition:** Set of codes for a policy that provides coverage for health care expenses arising from vision services.

A health insurance policy that covers benefits for vision care services, prescriptions, and products.


Code: _ActPatientSafetyIncidentCode
Display: ActPatientSafetyIncidentCode
Definition:
**Definition:** A code specifying the particular kind of Patient Safety Incident that the Incident class instance represents.

**Examples:**"Medication incident", "slips, trips and falls incident".The actual value set for the domain will be determined by each (realm) implementation, whose Patient Safety terminology will be specific, although probably linked to the WHO Patient Safety Taxonomy that is currently under development


Code: ACADR
Display: adverse drug reaction access
Definition:
**Description:** Provide consent to collect, use, disclose, or access adverse drug reaction information for a patient.


Code: ACALL
Display: all access
Definition:
**Description:** Provide consent to collect, use, disclose, or access all information for a patient.


Code: ACALLG
Display: allergy access
Definition:
**Description:** Provide consent to collect, use, disclose, or access allergy information for a patient.


Code: ACCONS
Display: informational consent access
Definition:
**Description:** Provide consent to collect, use, disclose, or access informational consent information for a patient.


Code: ACDEMO
Display: demographics access
Definition:
**Description:** Provide consent to collect, use, disclose, or access demographics information for a patient.


Code: ACDI
Display: diagnostic imaging access
Definition:
**Description:** Provide consent to collect, use, disclose, or access diagnostic imaging information for a patient.


Code: ACIMMUN
Display: immunization access
Definition:
**Description:** Provide consent to collect, use, disclose, or access immunization information for a patient.


Code: ACLAB
Display: lab test result access
Definition:
**Description:** Provide consent to collect, use, disclose, or access lab test result information for a patient.


Code: ACMED
Display: medication access
Definition:
**Description:** Provide consent to collect, use, disclose, or access medical condition information for a patient.


Code: ACMEN
Display: mental health access
Definition:
**Description:**Provide consent to collect, use, disclose, or access mental health information for a patient.


Code: ACOBS
Display: common observations access
Definition:
**Description:** Provide consent to collect, use, disclose, or access common observation information for a patient.


Code: ACPOLPRG
Display: policy or program information access
Definition:
**Description:** Provide consent to collect, use, disclose, or access coverage policy or program for a patient.


Code: ACPROV
Display: provider information access
Definition:
**Description:** Provide consent to collect, use, disclose, or access provider information for a patient.


Code: ACPSERV
Display: professional service access
Definition:
**Description:** Provide consent to collect, use, disclose, or access professional service information for a patient.


Code: ACSUBSTAB
Display: substance abuse access
Definition:
**Description:**Provide consent to collect, use, disclose, or access substance abuse information for a patient.


Code: INFAUT
Display: authorized information transfer
Definition:
Authorization to collect, access, use, or disclose specified patient health information in accordance with jurisdictional law, organizational policy, or a patient's consent directive, which may be implied, deemed, opt-in, opt-out, or explicit.


Code: INFCRT
Display: only on court order
Definition:
Authorization to collect, access, use, or disclose specified patient health information in accordance with judicial system protocol, such as in the case of a subpoena or court order.


Code: INFDNG
Display: only if danger to others
Definition:
Authorization to collect, access, use, or disclose specified patient health information where deemed necessary to avert potential danger to other persons in accordance with jurisdictional law, organizational policy, or standards of practice. For example, disclosure about a person threatening violence.


Code: INFEMER
Display: only in an emergency
Definition:
Authorization to collect, access, use, or disclose specified patient health information in accordance with emergency information transfer protocol dictated by jurisdictional law, organization policy, or standards of practice. For example, sharing of health information during disaster response.


Code: INFPWR
Display: only if public welfare risk
Definition:
Authorization to collect, access, use, or disclose specified patient health information necessary to avert potential public welfare risk in accordance with jurisdictional law, organizational policy, or standards of practice. For example, reporting that a person is a victim of abuse or demonstrating suicidal tendencies.


Code: INFREG
Display: regulatory information transfer
Definition:
Authorization to collect, access, use, or disclose specified patient health information for public health, welfare, and safety purposes in accordance with jurisdictional law, organizational policy, or standards of practice. For example, public health reporting of notifiable conditions.


Code: INFODEIDENTIFIY
Display: deidentify information
Definition:
Authorization to alter or remove identifying characteristics of an entity or individual that is a subject of the information.


Code: INFOREADONLY
Display: read only information
Definition:
Authorization to access information within a specific context for communication purposes only. Storing, manipulating, and further disclosure are prohibited and may be technically disabled.


Code: INFOREIDENTIFY
Display: reidentify information
Definition:
Authorization to alter or relink deidentified information so that an entity or individual that is the subject of that information identifiable.


Code: COBSCAT
Display: common observation category
Definition:
**Definition:**All information pertaining to a patient's common observation records (height, weight, blood pressure, temperature, etc.).


Code: DEMOCAT
Display: demographics category
Definition:
**Definition:**All information pertaining to a patient's demographics (such as name, date of birth, gender, address, etc).


Code: DICAT
Display: diagnostic image category
Definition:
**Definition:**All information pertaining to a patient's diagnostic image records (orders & results).


Code: PSVCCAT
Display: professional service category
Definition:
**Definition:**All information pertaining to a patient's professional service records (such as smoking cessation, counseling, medication review, mental health).


Code: RXCAT
Display: medication category
Definition:
**Definition:**All information pertaining to a patient's medication records (orders, dispenses and other active medications).


Code: OrgIP
Display: organizational information policy
Definition:
Organizational policy on collection, access, use, or disclosure of information, which does not conflict with jurisdictional law.


Code: ETH
Display: substance abuse information sensitivity
Definition:
Policy for handling alcohol or drug-abuse information, which will be afforded heightened confidentiality. Information handling protocols based on organizational policies related to alcohol or drug-abuse information that is deemed sensitive.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: GDIS
Display: genetic disease information sensitivity
Definition:
Policy for handling genetic disease information, which will be afforded heightened confidentiality. Information handling protocols based on organizational policies related to genetic disease information that is deemed sensitive.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: HIV
Display: HIV/AIDS information sensitivity
Definition:
Policy for handling HIV or AIDS information, which will be afforded heightened confidentiality. Information handling protocols based on organizational policies related to HIV or AIDS information that is deemed sensitive.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: MST
Display: military sexual trauma information sensitivity
Definition:
Policy for handling information related to sexual assault or repeated, threatening sexual harassment that occurred while the patient was in the military, which is afforded heightened confidentiality.

Access control concerns for military sexual trauma is based on the patient being subject to control by a higher ranking military perpetrator and/or censure by others within the military unit. Due to the relatively unfettered access to healthcare information by higher ranking military personnel and those who have command over the patient, there is a need to sequester this information outside of the typical controls on access to military health records.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law in addition to this more generic code.


Code: PREGNANT
Display: pregnancy information sensitivity
Definition:
Policy for handling information about an individual's current or past pregnancy status, deemed sensitive by the individual or by policy, which may be afforded heightened confidentiality.

*Usage Note:* 

Information about a patient's current or past pregnancy status may be considered sensitive in circumstances in which that status could result in discrimination or stigmatization.


Code: SCA
Display: sickle cell anemia information sensitivity
Definition:
Policy for handling sickle cell disease information, which is afforded heightened confidentiality. Information handling protocols are based on organizational policies related to sickle cell disease information, which is deemed sensitive.

*Usage Note:* If there is a jurisdictional mandate, then the Act valued with this ActCode should be associated with an Act valued with any applicable laws from the ActPrivacyLaw code system.


Code: SDV
Display: sexual assault, abuse, or domestic violence information sensitivity
Definition:
Policy for handling sexual assault, abuse, or domestic violence information, which will be afforded heightened confidentiality. Information handling protocols based on organizational policies related to sexual assault, abuse, or domestic violence information that is deemed sensitive.

SDV code covers violence perpetrated by related and non-related persons. This code should be specific to physical and mental trauma caused by a related person only. The access control concerns are keeping the patient safe from the perpetrator who may have an abusive psychological control over the patient, may be stalking the patient, or may try to manipulate care givers into allowing the perpetrator to make contact with the patient. The definition needs to be clarified.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: SEX
Display: sexuality and reproductive health information sensitivity
Definition:
Policy for handling sexuality and reproductive health information, which will be afforded heightened confidentiality. Information handling protocols based on organizational policies related to sexuality and reproductive health information that is deemed sensitive.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: SPI
Display: specially protected information sensitivity
Definition:
Policy for handling information deemed specially protected by law or policy including substance abuse, substance use, psychiatric, mental health, behavioral health, and cognitive disorders, which is afforded heightened confidentiality.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law in addition to this more generic code.


Code: STD
Display: sexually transmitted disease information sensitivity
Definition:
Policy for handling sexually transmitted disease information, which will be afforded heightened confidentiality. Information handling protocols based on organizational policies related to sexually transmitted disease information that is deemed sensitive.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: TBOO
Display: taboo
Definition:
Policy for handling information not to be initially disclosed or discussed with patient except by a physician assigned to patient in this case. Information handling protocols based on organizational policies related to sensitive patient information that must be initially discussed with the patient by an attending physician before being disclosed to the patient.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.

*Open Issue:* This definition conflates a rule and a characteristic, and there may be a similar issue with ts sibling codes.


Code: VIO
Display: violence information sensitivity
Definition:
Policy for handling information related to harm by violence, which is afforded heightened confidentiality. Harm by violence is perpetrated by an unrelated person.

Access control concerns for information about mental or physical harm resulting from violence caused by an unrelated person may include manipulation of care givers or access to records that enable the perpetrator contact or locate the patient, but the perpetrator will likely not have established abusive psychological control over the patient.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law in addition to this more generic code.


Code: IDS
Display: Identifier Sensitivity
Definition:
Policy for handling information related to an identifier of an information subject, which will be afforded heightened confidentiality. Usage Note: Such policies may govern the sensitivity of information related to an identifier of an act, such as the identifier of a contract; a role, such as a citizen, a patient, a practitioner, or an organization; or an entity such as a medical device due to potential impact on the privacy, well-being, safety or integrity of an information subject. For example, protection against identity fraud or counterfeit.


Code: SICKLE
Display: sickle cell
Definition:
Types of sensitivity policies that apply to Acts. Act.confidentialityCode is defined in the RIM as "constraints around appropriate disclosure of information about this Act, regardless of mood."

*Usage Note:* ActSensitivity codes are used to bind information to an Act.confidentialityCode according to local sensitivity policy so that those confidentiality codes can then govern its handling across enterprises. Internally to a policy domain, however, local policies guide the access control system on how end users in that policy domain are able to use information tagged with these sensitivity values.


Code: AUTOPOL
Display: automobile
Definition:
Insurance policy for injuries sustained in an automobile accident. Will also typically covered non-named parties to the policy, such as pedestrians and passengers.


Code: PUBLICPOL
Display: public healthcare
Definition:
Insurance policy funded by a public health system such as a provincial or national health plan. Examples include BC MSP (British Columbia Medical Services Plan) OHIP (Ontario Health Insurance Plan), NHS (National Health Service).


Code: DIS
Display: disability insurance policy
Definition:
**Definition:** An insurance policy that provides a regular payment to compensate for income lost due to the covered party's inability to work because of illness or injury.


Code: EWB
Display: employee welfare benefit plan policy
Definition:
**Definition:** An insurance policy under a benefit plan run by an employer or employee organization for the purpose of providing benefits other than pension-related to employees and their families. Typically provides health-related benefits, benefits for disability, disease or unemployment, or day care and scholarship benefits, among others. An employer sponsored health policy includes coverage of health care expenses arising from sickness or accidental injury, coverage for on-site medical clinics or for dental or vision benefits, which are typically provided under a separate policy. Coverage excludes health care expenses covered by accident or disability, workers' compensation, liability or automobile insurance.


Code: FLEXP
Display: flexible benefit plan policy
Definition:
**Definition:**  An insurance policy that covers qualified benefits under a Flexible Benefit plan such as group medical insurance, long and short term disability income insurance, group term life insurance for employees only up to $50,000 face amount, specified disease coverage such as a cancer policy, dental and/or vision insurance, hospital indemnity insurance, accidental death and dismemberment insurance, a medical expense reimbursement plan and a dependent care reimbursement plan.

 *Discussion:* See UnderwriterRoleTypeCode flexible benefit plan which is defined as a benefit plan that allows employees to choose from several life, health, disability, dental, and other insurance plans according to their individual needs. Also known as cafeteria plans. Authorized under Section 125 of the Revenue Act of 1978.


Code: PNC
Display: property and casualty insurance policy
Definition:
**Definition:** A type of insurance that covers damage to or loss of the policyholderaTMs property by providing payments for damages to property damage or the injury or death of living subjects. The terms "casualty" and "liability" insurance are often used interchangeably. Both cover the policyholder's legal liability for damages caused to other persons and/or their property.


Code: REI
Display: reinsurance policy
Definition:
**Definition:** An agreement between two or more insurance companies by which the risk of loss is proportioned. Thus the risk of loss is spread and a disproportionately large loss under a single policy does not fall on one insurance company. Acceptance by an insurer, called a reinsurer, of all or part of the risk of loss of another insurance company.

**Discussion:** Reinsurance is a means by which an insurance company can protect itself against the risk of losses with other insurance companies. Individuals and corporations obtain insurance policies to provide protection for various risks (hurricanes, earthquakes, lawsuits, collisions, sickness and death, etc.). Reinsurers, in turn, provide insurance to insurance companies.

For example, an HMO may purchase a reinsurance policy to protect itself from losing too much money from one insured's particularly expensive health care costs. An insurance company issuing an automobile liability policy, with a limit of $100,000 per accident may reinsure its liability in excess of $10,000. A fire insurance company which issues a large policy generally reinsures a portion of the risk with one or several other companies. Also called *risk control insurance or stop-loss insurance.*


Code: SURPL
Display: surplus line insurance policy
Definition:
**Definition:** 

1.  A risk or part of a risk for which there is no normal insurance market available.
2.  Insurance written by unauthorized insurance companies. Surplus lines insurance is insurance placed with unauthorized insurance companies through licensed surplus lines agents or brokers.


Code: UMBRL
Display: umbrella liability insurance policy
Definition:
**Definition:** A form of insurance protection that provides additional liability coverage after the limits of your underlying policy are reached. An umbrella liability policy also protects you (the insured) in many situations not covered by the usual liability policies.


Code: ALEC
Display: alternate electronic
Definition:
Payment initiated by the payor as the result of adjudicating a submitted invoice that arrived to the payor from an electronic source that did not provide a conformant set of HL7 messages (e.g. web claim submission).


Code: CFWD
Display: carry forward adjusment
Definition:
An amount still owing to the payor but the payment is 0$ and this cannot be settled until a future payment is made.


Code: EPYMT
Display: early payment fee
Definition:
Fees deducted on behalf of a payee for charges based on a shorter payment frequency (i.e. next day versus biweekly payments.


Code: GARN
Display: garnishee
Definition:
Fees deducted on behalf of a payee for charges based on a per-transaction or time-period (e.g. monthly) fee.


Code: INVOICE
Display: submitted invoice
Definition:
Payment is based on a payment intent for a previously submitted Invoice, based on formal adjudication results..


Code: PINV
Display: paper invoice
Definition:
Payment initiated by the payor as the result of adjudicating a paper (original, may have been faxed) invoice.


Code: PPRD
Display: prior period adjustment
Definition:
An amount that was owed to the payor as indicated, by a carry forward adjusment, in a previous payment advice


Code: PROA
Display: professional association deduction
Definition:
Professional association fee that is collected by the payor from the practitioner/provider on behalf of the association


Code: SENDAPP
Display: sending application
Definition:
Transaction counts and value totals by each instance of a messaging application on a single processor. It is a registered identifier known to the receivers.


Code: _HCPCS
Display: HCPCS
Definition:
**Description:**Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes are procedure identifying codes. HCPCS is Health Care Finance AdministrationaTMs (HFCA) coding scheme to group procedures performed for payment to providers. contains codes for medical equipment, injectable drugs, transportation services, and other services not found in CPT4.


Code: _ICD10PCS
Display: ICD10PCS
Definition:
**Description:**International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) are procedure identifying codes. ICD-10-PCS describes the classification of inpatient procedures for statistical purposes.


Code: _ICD9PCS
Display: ICD9PCS
Definition:
**Description:**International Classification of Diseases, 9th Revision, Procedure Coding System (ICD-9-PCS) are procedure identifying codes. ICD-9-PCS describes the classification of inpatient procedures for statistical purposes.


Code: COIN
Display: coinsurance
Definition:
That portion of the eligible charges which a covered party must pay for each service and/or product. It is a percentage of the eligible amount for the service/product that is typically charged after the covered party has met the policy deductible. This amount represents the covered party's coinsurance that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.


Code: COPAYMENT
Display: patient co-pay
Definition:
That portion of the eligible charges which a covered party must pay for each service and/or product. It is a defined amount per service/product of the eligible amount for the service/product. This amount represents the covered party's copayment that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.


Code: DEDUCTIBLE
Display: deductible
Definition:
That portion of the eligible charges which a covered party must pay in a particular period (e.g. annual) before the benefits are payable by the adjudicator. This amount represents the covered party's deductible that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results.


Code: PAY
Display: payment
Definition:
The guarantor, who may be the patient, pays the entire charge for a service. Reasons for such action may include: there is no insurance coverage for the service (e.g. cosmetic surgery); the patient wishes to self-pay for the service; or the insurer denies payment for the service due to contractual provisions such as the need for prior authorization.


Code: SPEND
Display: spend down
Definition:
That total amount of the eligible charges which a covered party must periodically pay for services and/or products prior to the Medicaid program providing any coverage. This amount represents the covered party's spend down that is applied to a particular adjudication result. It is expressed as a negative dollar amount in adjudication results


Code: OOO
Display: out of office
Definition:
Premium paid on service fees in compensation for practicing at a location other than normal working location.


Code: CANCAPT
Display: cancelled appointment
Definition:
A charge to compensate the provider when a patient cancels an appointment with insufficient time for the provider to make another appointment with another patient.


Code: DSC
Display: discount
Definition:
A reduction in the amount charged as a percentage of the amount. For example a 5% discount for volume purchase.


Code: ESA
Display: extraordinary service assessment
Definition:
A premium on a service fee is requested because, due to extenuating circumstances, the service took an extraordinary amount of time or supplies.


Code: FFSTOP
Display: fee for service top off
Definition:
Under agreement between the parties (payor and provider), a guaranteed level of income is established for the provider over a specific, pre-determined period of time. The normal course of business for the provider is submission of fee-for-service claims. Should the fee-for-service income during the specified period of time be less than the agreed to amount, a top-up amount is paid to the provider equal to the difference between the fee-for-service total and the guaranteed income amount for that period of time. The details of the agreement may specify (or not) a requirement for repayment to the payor in the event that the fee-for-service income exceeds the guaranteed amount.


Code: MARKUP
Display: markup or up-charge
Definition:
An increase in the amount charged as a percentage of the amount. For example, 12% markup on product cost.


Code: PERFEE
Display: periodic fee
Definition:
Anticipated or actual periodic fee associated with treating a patient. For example, expected billing cycle such as monthly, quarterly. The actual period (e.g. monthly, quarterly) is specified in the unit quantity of the Invoice Element.


Code: PERMBNS
Display: performance bonus
Definition:
The amount for a performance bonus that is being requested from a payor for the performance of certain services (childhood immunizations, influenza immunizations, mammograms, pap smears) on a sliding scale. That is, for 90% of childhood immunizations to a maximum of $2200/yr. An invoice is created at the end of the service period (one year) and a code is submitted indicating the percentage achieved and the dollar amount claimed.


Code: RESTOCK
Display: restocking fee
Definition:
A charge is requested because the patient failed to pick up the item and it took an amount of time to return it to stock for future use.


Code: TRAVEL
Display: travel
Definition:
A charge to cover the cost of travel time and/or cost in conjuction with providing a service or product. It may be charged per kilometer or per hour based on the effective agreement.


Code: URGENT
Display: urgent
Definition:
Premium paid on service fees in compensation for providing an expedited response to an urgent situation.


Code: CPNDDRGING
Display: compound drug invoice group
Definition:
A grouping of invoice element groups and details including the ones specifying the compound ingredients being invoiced. It may also contain generic detail items such as markup.


Code: CPNDINDING
Display: compound ingredient invoice group
Definition:
A grouping of invoice element details including the one specifying an ingredient drug being invoiced. It may also contain generic detail items such as tax or markup.


Code: CPNDSUPING
Display: compound supply invoice group
Definition:
A grouping of invoice element groups and details including the ones specifying the compound supplies being invoiced. It may also contain generic detail items such as markup.


Code: DRUGING
Display: drug invoice group
Definition:
A grouping of invoice element details including the one specifying the drug being invoiced. It may also contain generic detail items such as markup.


Code: FRAMEING
Display: frame invoice group
Definition:
A grouping of invoice element details including the ones specifying the frame fee and the frame dispensing cost that are being invoiced.


Code: LENSING
Display: lens invoice group
Definition:
A grouping of invoice element details including the ones specifying the lens fee and the lens dispensing cost that are being invoiced.


Code: PRDING
Display: product invoice group
Definition:
A grouping of invoice element details including the one specifying the product (good or supply) being invoiced. It may also contain generic detail items such as tax or discount.


Code: COVGE
Display: coverage problem
Definition:
Insurance coverage problems have been encountered. Additional explanation information to be supplied.


Code: GFTH
Display: good faith indicator
Definition:
The medical service was provided to a patient in good faith that they had medical coverage, although no evidence of coverage was available before service was rendered.


Code: LATE
Display: late invoice
Definition:
Knowingly over the payor's published time limit for this invoice possibly due to a previous payor's delays in processing. Additional reason information will be supplied.


Code: MANUAL
Display: manual review
Definition:
Manual review of the invoice is requested. Additional information to be supplied. This may be used in the case of an appeal.


Code: OOJ
Display: out of jurisdiction
Definition:
The medical service and/or product was provided to a patient that has coverage in another jurisdiction.


Code: ORTHO
Display: orthodontic service
Definition:
The service provided is required for orthodontic purposes. If the covered party has orthodontic coverage, then the service may be paid.


Code: PIE
Display: public insurance exhausted
Definition:
Public Insurance has been exhausted. Invoice has not been sent to Public Insuror and therefore no Explanation Of Benefits (EOB) is provided with this Invoice submission.


Code: REFNR
Display: referral not required
Definition:
Rules of practice do not require a physician's referral for the provider to perform a billable service.


Code: REPSERV
Display: repeated service
Definition:
The same service was delivered within a time period that would usually indicate a duplicate billing. However, the repeated service is a medical necessity and therefore not a duplicate.


Code: UNRELAT
Display: unrelated service
Definition:
The service provided is not related to another billed service. For example, 2 unrelated services provided on the same day to the same patient which may normally result in a refused payment for one of the items.


Code: VERBAUTH
Display: verbal authorization
Definition:
The provider has received a verbal permission from an authoritative source to perform the service or supply the item being invoiced.


Code: CPINV
Display: clinical product invoice
Definition:
Clinical product invoice where the Invoice Grouping contains one or more billable item and is supported by clinical product(s).

For example, a crutch or a wheelchair.


Code: CSINV
Display: clinical service invoice
Definition:
Clinical Services Invoice which can be used to describe a single service, multiple services or repeated services.

\[1\] Single Clinical services invoice where the Invoice Grouping contains one billable item and is supported by one clinical service.

For example, a single service for an office visit or simple clinical procedure (e.g. knee mobilization).

\[2\] Multiple Clinical services invoice where the Invoice Grouping contains more than one billable item, supported by one or more clinical services. The services can be distinct and over multiple dates, but for the same patient. This type of invoice includes a series of treatments which must be adjudicated together.

For example, an adjustment and ultrasound for a chiropractic session where fees are associated for each of the services and adjudicated (invoiced) together.

\[3\] Repeated Clinical services invoice where the Invoice Grouping contains one or more billable item, supported by the same clinical service repeated over a period of time.

For example, the same Chiropractic adjustment (service or treatment) delivered on 3 separate occasions over a period of time at the discretion of the provider (e.g. month).


Code: CSPINV
Display: clinical service and product
Definition:
A clinical Invoice Grouping consisting of one or more services and one or more product. Billing for these service(s) and product(s) are supported by multiple clinical billable events (acts).

All items in the Invoice Grouping must be adjudicated together to be acceptable to the Adjudicator.

For example , a brace (product) invoiced together with the fitting (service).


Code: FININV
Display: financial invoice
Definition:
Invoice Grouping without clinical justification. These will not require identification of participants and associations from a clinical context such as patient and provider.

Examples are interest charges and mileage.


Code: OHSINV
Display: oral health service
Definition:
A clinical Invoice Grouping consisting of one or more oral health services. Billing for these service(s) are supported by multiple clinical billable events (acts).

All items in the Invoice Grouping must be adjudicated together to be acceptable to the Adjudicator.


Code: SBFINV
Display: sessional or block fee invoice
Definition:
Clinical services invoice where the Invoice Group contains one billable item for multiple clinical services in one or more sessions.


Code: VRXINV
Display: vision dispense invoice
Definition:
Vision dispense invoice for up to 2 lens (left and right), frame and optional discount. Eye exams are invoiced as a clinical service invoice.


Code: _ActProcedureCategoryList
Display: ActProcedureCategoryList
Definition:
**Description:**Describes the high level classification of professional services for grouping.

**Examples:**Education, Counseling, Surgery, etc.


Code: ALC
Display: Alternative Level of Care
Definition:
Provision of Alternate Level of Care to a patient in an acute bed. Patient is waiting for placement in a long-term care facility and is unable to return home.


Code: GENRL
Display: General
Definition:
General care performed by a general practitioner or family doctor as a responsible provider for a patient.


Code: OBS
Display: Obstetrics
Definition:
Provision of care of women during pregnancy, childbirth and immediate postpartum period. Also known as Maternity.


Code: ACU
Display: short term/acute
Definition:
**Definition:**A list of medications which the patient is only expected to consume for the duration of the current order or limited set of orders and which is not expected to be renewed.


Code: CHRON
Display: continuous/chronic
Definition:
**Definition:**A list of medications which are expected to be continued beyond the present order and which the patient should be assumed to be taking unless explicitly stopped.


Code: PRN
Display: as needed
Definition:
**Definition:**A list of medications which the patient will consume intermittently based on the behavior of the condition for which the medication is indicated.


Code: INV
Display: investigational
Definition:
**Definition:**A monitoring program that focuses on a drug which is under investigation and has not received regulatory approval for the condition being investigated


Code: OTC
Display: non prescription medicine
Definition:
Medicines designated in this way may be supplied for patient use without a prescription. The exact form of categorisation will vary in different realms.


Code: RX
Display: prescription only medicine
Definition:
Some form of prescription is required before the related medicine can be supplied for a patient. The exact form of regulation will vary in different realms.


Code: IND02
Display: colonoscopy prep
Definition:
**Description:**Provision of prescription or direction to consume a product for purposes of bowel clearance in preparation for a colonoscopy.


Code: IND03
Display: prophylaxis
Definition:
**Description:**Provision of medication as a preventative measure during a treatment or other period of increased risk.


Code: IND04
Display: surgical prophylaxis
Definition:
**Description:**Provision of medication during pre-operative phase; e.g., antibiotics before dental surgery or bowel prep before colon surgery.


Code: IND05
Display: pregnancy prophylaxis
Definition:
**Description:**Provision of medication for pregnancy --e.g., vitamins, antibiotic treatments for vaginal tract colonization, etc.


Code: CARELIST
Display: care plan
Definition:
List of acts representing a care plan. The acts can be in a varierty of moods including event (EVN) to record acts that have been carried out as part of the care plan.


Code: VFPAPER
Display: verify paper
Definition:
**Definition:**Indicates that the paper version of the record has, should be or is being verified against the electronic version.


Code: ANNDI
Display: diagnostic image note
Definition:
**Description:**A note that is specific to a patient's diagnostic images, either historical, current or planned.


Code: ANNLAB
Display: laboratory note
Definition:
**Description:**A note that is specific to a patient's laboratory results, either historical, current or planned.


Code: ANNMED
Display: medication note
Definition:
**Description:**A note that is specific to a patient's medications, either historical, current or planned.


Code: UDE
Display: unit dose equivalent
Definition:
A supply action that provides sufficient material for a single dose via multiple products. E.g. 2 50mg tablets for a 100mg unit dose.


Code: _ActConsent
Display: _ActConsent
Definition:
Specifies the type or actual definition of a contractually binding agreement or a non-binding representation of that agreement between a grantor and a grantee as to the exchange of the grantee's considerations in return for the grantor's control of certain assets. The type of assets exchanged include rights, license, terms of service, valued items, information and real property assets and control over such assets such as physical and locatable property; intellectual property; biospecimen; genomic and genetic information related to an individual including that disclosed by genetically related individuals with or without the individual's consent; personal identifiable, pseudonymized, anonymized, de-identified per some rubric, and relinkable variants.

*Usage Note:* Types or actual definitions of a contractually binding agreement or a non-binding representation of that agreement include:

 *  \_ActDecision (formally ActConsentDirective), which specifies the type of decision made by the grantor. The decision types are mapped to ISO/TS 17975 Health informatics - Principles and data requirements for consent in the Collection, Use or Disclosure of personal health information;
 *  \_ActPrivacyConsentDirective, which is the parent of types of registry participation consent directives, and of realm specific privacy consent directive policies such as \_USPrivacyConsentDirective and \_GDPRPrivacyConsentDirective.


Code: _ActInformationPolicy
Display: _ActInformationPolicy
Definition:
Information management directives related to privacy, security, integrity, and control concerns, which may be governed by specific laws; based on private sector self-governance; adopted "best practices" recognized by a community of interest; or terms of license, participation, or service as implemented in jurisdictional, organizational, or personal policies.


Code: _ActPrivacyPolicy
Display: ActPrivacyPolicy
Definition:
A policy deeming certain information to be private to an individual or organization.

*Definition:* A mandate, obligation, requirement, rule, or expectation relating to privacy.

*Discussion:* ActPrivacyPolicyType codes support the designation of the 1..\* policies that are applicable to an Act such as a Consent Directive, a Role such as a VIP Patient, or an Entity such as a patient who is a minor. 1..\* ActPrivacyPolicyType values may be associated with an Act or Role to indicate the policies that govern the assignment of an Act or Role confidentialityCode. Use of multiple ActPrivacyPolicyType values enables fine grain specification of applicable policies, but must be carefully assigned to ensure cogency and avoid creation of conflicting policy mandates.

*Usage Note:* Statutory title may be named in the ActClassPolicy Act Act.title to specify which privacy policy is being referenced.


Code: ActTrustPolicyType
Display: trust policy
Definition:
A mandate, obligation, requirement, rule, or expectation conveyed as security metadata between senders and receivers required to establish the reliability, authenticity, and trustworthiness of their transactions.

Trust security metadata are observation made about aspects of trust applicable to an IT resource (data, information object, service, or system capability).

Trust applicable to IT resources is established and maintained in and among security domains, and may be comprised of observations about the domain's trust authority, trust framework, trust policy, trust interaction rules, means for assessing and monitoring adherence to trust policies, mechanisms that enforce trust, and quality and reliability measures of assurance in those mechanisms. \[Based on ISO IEC 10181-1 and NIST SP 800-63-2\]

For example, identity proofing , level of assurance, and Trust Framework.


Code: COVPOL
Display: benefit policy
Definition:
**Description:**A mandate, obligation, requirement, rule, or expectation unilaterally imposed on benefit coverage under a policy or program by a sponsor, underwriter or payor on:

 *  The activity of another party
 *  The behavior of another party
 *  The manner in which an act is executed

**Examples:**A clinical protocol imposed by a payer to which a provider must adhere in order to be paid for providing the service. A formulary from which a provider must select prescribed drugs in order for the patient to incur a lower copay.


Code: SecurityPolicy
Display: security policy
Definition:
Types of security policies that further specify the ActClassPolicy value set.

**Examples:**

 *  obligation to encrypt
 *  refrain from redisclosure without consent


Code: _ActGenericConsentDirective
Display: _ActGenericConsentDirective
Definition:
Specifies types of consent directives authorizing a registry or repository to collect and, under certain terms, manage the access, use, and disclosure of personal information, including de-identified information, and personal effects, such as biometrics, biospecimen or genetic material, which may be used to identify an individual.

Registries governed by registry consent directives are data management systems, which use metadata to support the collection, access, use, and disclosure of personal information or effects as well as observational or analytic information generated about personal information or effects stored in federated repositories. Such registries are used for a variety of purposes by federated health information exchanges, health information systems, personal record systems, and research organizations to locate and retrieve personal information or effects as well as observational or analytic information generated about personal information stored externally to their systems.

Repositories governed by registry consent directives are data stores used to collect, access, use, and disclose personal information or effects as well as observational or analytic information generated about personal information or effects and metadata used to manage the repository contents. Such repositories are used for a variety of purposes by centralized health information exchanges, health information systems used by providers and payers, personal record systems, and research organizations. A repository typically includes a registry component that provides the data store with content management capabilities for internal purposes. A repository may also interface with one or more external registries, which provide federated content management.


Code: _ActUSPrivacyConsentDirective
Display: _ActUSPrivacyConsentDirective
Definition:
Specific US privacy consent directives in accordance with US federal, state, regional, organizational, or personal privacy policies.


Code: _ActGDPRPrivacyLaw
Display: General Data Protection Regulation
Definition:
GDPR is a regulation on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (Data Protection Directive). Promulgated by the European Parliament and Council of the European Union. Regulation available at L119, 4 May 2016, p. 1-88.

GDPR privacy policies specifying types of lawful personal data processing based on a controller meeting one or more processing condition such as specified by law, compliance with data controller legal obligations, protection of data subject's vital interests, perform tasks in the public interest, related to legal claims, research and statistics, management of health or social care systems, legitimate interests of controller or third party. Processing sensitive personal data, including genetic, biometric and health data, as well as personal data from which racial and ethnic origin, political opinions, religious or ideological convictions or membership in a union can be attributed to a person, requires meeting at least one sensitive personal processing condition.

GDPR 'processing' means any operation or set of operations which is performed on personal data or on sets of personal data, whether or not by automated means, such as collection, recording, organisation, structuring, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, restriction, erasure or destruction. Article 4 https://gdpr-info.eu/art-4-gdpr/

*Usage Note:* 

 *  Confidentiality: e.g., U (unrestricted) for anonymized personal information; L (low) for pseudonymized U (unrestricted) for anonymized personal information; M (moderate) for indirectly identifiable information such as test scores and work times; N (normal) for personal information; and R (restricted) for sensitive personal information
 *  DPR sensitivity \[personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs, or trade union membership, and the processing of genetic data, biometric data for the purpose of uniquely identifying a natural person, data concerning health or data concerning a natural person's sex life or sexual orientation, some of which are defined at Article 4 https://gdpr-info.eu/art-4-gdpr/
 *  GDPR processing policies and GDPR ConsentDirectiveTypes, such as data subject consent and research consent.
 *  Other security category codes, such as compartment codes for legitimate relationship,
 *  Handling instructions including
 *  Purpose of use stipulated in a GDPR consent or contract restricting processing or related to the scope of the processing policy such as public health, research, and legal obligations
 *  Obligation policies such as GDPR Information Obligations https://gdpr-info.eu/issues/information-obligations, data minimization and deleting when processing is complete
 *  Refrain policies such as no relinking

See Intersoft GDPR at https://gdpr-info.eu/issues/personal-data/ Art. 4 GDPR Definitions https://gdpr-info.eu/art-4-gdpr/ Art. 9 GDPR Processing of special categories of personal data https://gdpr-info.eu/art-9-gdpr/ Relevant Recitals (26) Not applicable to anonymous data (30) Online identifiers for profiling and identification (34) Genetic data (35) Health data (51) Protecting sensitive personal data at Intersoft GDPR briefing papers and navigating tool https://gdpr-info.eu/

Authorities

 *  European Data Protection Supervisor - Security Measures for Personal Data Processing (Link)
 *  Data Protection Authority Isle of Man - Know your data - Mapping the 5 W's (Link)
 *  Data Protection Authority UK - Key definitions (Link)
 *  European Commission - What is personal data? (Link)
 *  European Commission - What personal data is considered sensitive? (Link)
 *  EU publications - Handbook on European data protection law - Personal data, page 83 (Link)

Expert contribution A&L Goodbody - The GDPR: A Guide for Businesses - Definition of Personal & Sensitive Data, Page 8 (Link) Bird & Bird - Sensitive data and lawful processing (Link) https://ec.europa.eu/commission/priorities/justice-and-fundamental-rights/data-protection/2018-reform-eu-data-protection-rules\_en General Data Protection Regulation https://eur-lex.europa.eu/legal-content/EN/TXT/?qid=1528874672298&uri=CELEX%3A32016R0679 Communication on data protection - guidance on direct application of the GDPR http://eur-lex.europa.eu/legal-content/EN/TXT/?qid=1517578296944&uri=CELEX%3A52018DC0043 Intersoft GDPR briefing papers and navigating tool https://gdpr-info.eu/


Code: _ActUSPrivacyLaw
Display: _ActUSPrivacyLaw
Definition:
*Definition:* A jurisdictional mandate in the U.S. relating to privacy.

*Usage Note:* ActPrivacyLaw codes may be associated with an Act or a Role to indicate the legal provision to which the assignment of an Act.confidentialityCode or Role.confidentialtyCode complies. May be used to further specify rationale for assignment of other ActPrivacyPolicy codes in the US realm, e.g., ETH and 42CFRPart2 can be differentiated from ETH and Title38Part1.


Code: _ActPrivacyLaw
Display: ActPrivacyLaw
Definition:
A jurisdictional mandate, regulation, obligation, requirement, rule, or expectation deeming certain information to be private to an individual or organization, which is imposed on:

 *  The activity of a governed party
 *  The behavior of a governed party
 *  The manner in which an act is executed by a governed party


Code: _InformationSensitivityPolicy
Display: InformationSensitivityPolicy
Definition:
A mandate, obligation, requirement, rule, or expectation characterizing the value or importance of a resource and may include its vulnerability. (Based on ISO7498-2:1989. Note: The vulnerability of personally identifiable sensitive information may be based on concerns that the unauthorized disclosure may result in social stigmatization or discrimination.) Description: Types of Sensitivity policy that apply to Acts or Roles. A sensitivity policy is adopted by an enterprise or group of enterprises (a 'policy domain') through a formal data use agreement that stipulates the value, importance, and vulnerability of information. A sensitivity code representing a sensitivity policy may be associated with criteria such as categories of information or sets of information identifiers (e.g., a value set of clinical codes or branch in a code system hierarchy). These criteria may in turn be used for the Policy Decision Point in a Security Engine. A sensitivity code may be used to set the confidentiality code used on information about Acts and Roles to trigger the security mechanisms required to control how security principals (i.e., a person, a machine, a software application) may act on the information (e.g., collection, access, use, or disclosure). Sensitivity codes are never assigned to the transport or business envelope containing patient specific information being exchanged outside of a policy domain as this would disclose the information intended to be protected by the policy. When sensitive information is exchanged with others outside of a policy domain, the confidentiality code on the transport or business envelope conveys the receiver's responsibilities and indicates the how the information is to be safeguarded without unauthorized disclosure of the sensitive information. This ensures that sensitive information is treated by receivers as the sender intends, accomplishing interoperability without point to point negotiations.

*Usage Note:* Sensitivity codes are not useful for interoperability outside of a policy domain because sensitivity policies are typically localized and vary drastically across policy domains even for the same information category because of differing organizational business rules, security policies, and jurisdictional requirements. For example, an employee's sensitivity code would make little sense for use outside of a policy domain. 'Taboo' would rarely be useful outside of a policy domain unless there are jurisdictional requirements requiring that a provider disclose sensitive information to a patient directly. Sensitivity codes may be more appropriate in a legacy system's Master Files in order to notify those who access a patient's orders and observations about the sensitivity policies that apply. Newer systems may have a security engine that uses a sensitivity policy's criteria directly. The specializable InformationSensitivityPolicy Act.code may be useful in some scenarios if used in combination with a sensitivity identifier and/or Act.title.


Code: COMPT
Display: compartment
Definition:
This is the healthcare analog to the US Intelligence Community's concept of a Special Access Program. Compartment codes may be used in as a field value in an initiator's clearance to indicate permission to access and use an IT Resource with a security label having the same compartment value in security category label field.

Map: Aligns with ISO 2382-8 definition of Compartment - "A division of data into isolated blocks with separate security controls for the purpose of reducing risk."


Code: _ActBillableServiceCode
Display: ActBillableServiceCode
Definition:
**Definition:** An identifying code for billable services, as opposed to codes for similar services used to identify them for functional purposes.


Code: CHAR
Display: charity program
Definition:
**Definition:** A program that covers the cost of services provided directly to a beneficiary who typically has no other source of coverage without charge.


Code: CRIME
Display: crime victim program
Definition:
**Definition:** A program that covers the cost of services provided to crime victims for injuries or losses related to the occurrence of a crime.


Code: EAP
Display: employee assistance program
Definition:
**Definition:** An employee assistance program is run by an employer or employee organization for the purpose of providing benefits and covering all or part of the cost for employees to receive counseling, referrals, and advice in dealing with stressful issues in their lives. These may include substance abuse, bereavement, marital problems, weight issues, or general wellness issues. The services are usually provided by a third-party, rather than the company itself, and the company receives only summary statistical data from the service provider. Employee's names and services received are kept confidential.


Code: GOVEMP
Display: government employee health program
Definition:
**Definition:** A set of codes used to indicate a government program that is an organized structure for administering and funding coverage of a benefit package for covered parties meeting eligibility criteria, typically related to employment, health and financial status. Government programs are established or permitted by legislation with provisions for ongoing government oversight. Regulation mandates the structure of the program, the manner in which it is funded and administered, covered benefits, provider types, eligibility criteria and financial participation. A government agency is charged with implementing the program in accordance to the regulation

**Example:** Federal employee health benefit program in the U.S.


Code: HIRISK
Display: high risk pool program
Definition:
**Definition:** A government program that provides health coverage to individuals who are considered medically uninsurable or high risk, and who have been denied health insurance due to a serious health condition. In certain cases, it also applies to those who have been quoted very high premiums a" again, due to a serious health condition. The pool charges premiums for coverage. Because the pool covers high-risk people, it incurs a higher level of claims than premiums can cover. The insurance industry pays into the pool to make up the difference and help it remain viable.


Code: IND
Display: indigenous peoples health program
Definition:
**Definition:** Services provided directly and through contracted and operated indigenous peoples health programs.

**Example:** Indian Health Service in the U.S.


Code: MILITARY
Display: military health program
Definition:
**Definition:** A government program that provides coverage for health services to military personnel, retirees, and dependents. A covered party who is a subscriber can choose from among Fee-for-Service (FFS) plans, and their Preferred Provider Organizations (PPO), or Plans offering a Point of Service (POS) Product, or Health Maintenance Organizations.

**Example:** In the U.S., TRICARE, CHAMPUS.


Code: RETIRE
Display: retiree health program
Definition:
**Definition:** A government mandated program with specific eligibility requirements based on premium contributions made during employment, length of employment, age, and employment status, e.g., being retired, disabled, or a dependent of a covered party under this program. Benefits typically include ambulatory, inpatient, and long-term care, such as hospice care, home health care and respite care.


Code: SOCIAL
Display: social service program
Definition:
**Definition:** A social service program funded by a public or governmental entity.

**Example:** Programs providing habilitation, food, lodging, medicine, transportation, equipment, devices, products, education, training, counseling, alteration of living or work space, and other resources to persons meeting eligibility criteria.


Code: VET
Display: veteran health program
Definition:
**Definition:** Services provided directly and through contracted and operated veteran health programs.


Code: NEUT
Display: Neutralization
Definition:
The act or process by which an acid and a base are combined in such proportions that the resulting compound is neutral.


Code: UFIL
Display: Ultrafiltration
Definition:
The filtration of a colloidal substance through a semipermeable medium that allows only the passage of small molecules.


Code: DRUG
Display: Drug therapy
Definition:
The introduction of a drug into a subject with the intention of altering its biologic state with the intent of improving its health status.


Code: FD
Display: food
Definition:
**Description:** The introduction of material into a subject with the intent of providing nutrition or other dietary supplements (e.g. minerals or vitamins).


Code: HISTORIC
Display: record recorded as historical
Definition:
**Description:** While the record was accepted in the repository, there is a more recent version of a record of this type.


Code: PATPREF
Display: violates stated preferences
Definition:
**Definition:**The proposed therapy goes against preferences or consent constraints recorded in the patient's record.


Code: 42CFRPart2CD
Display: 42 CFR Part 2 consent directive
Definition:
A code representing an individual's privacy consent directive that complies with 42 CFR Part 2.31 Consent requirements https://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol1/pdf/CFR-2017-title42-vol1-sec2-31.pdf, which is a US Federal law stipulating the policy elements of a written consent to a disclosure under the regulations in Part 2.

(1) The name of the patient. (2) The specific name(s) or general designation(s) of the part 2 program(s), entity(ies), or individual(s) permitted to make the disclosure. (3) How much and what kind of information is to be disclosed, including an explicit description of the substance use disorder information that may be disclosed. (4) (i) The name(s) of the individual(s) to whom a disclosure is to be made; or (ii)Entities with a treating provider relationship with the patient. If the recipient entity has a treating provider relationship with the patient whose information is being disclosed, such as a hospital, a health care clinic, or a private practice, the name of that entity; or (iii)Entities without a treating provider relationship with the patient. (A) If the recipient entity does not have a treating provider relationship with the patient whose information is being disclosed and is a third-party payer, the name of the entity; or (B) If the recipient entity does not have a treating provider relationship with the patient whose information is being disclosed and is not covered by paragraph (a)(4)(iii)(A) of this section, such as an entity that facilitates the exchange of health information or a research institution, the name(s) of the entity(-ies); and (1) The name(s) of an individual participant(s); or (2) The name(s) of an entity participant(s) that has a treating provider relationship with the patient whose information is being disclosed; or (3) A general designation of an individual or entity participant(s) or class of participants that must be limited to a participant(s) who has a treating provider relationship with the patient whose information is being disclosed. (i) When using a general designation, a statement must be included on the consent form that the patient (or other individual authorized to sign in lieu of the patient), confirms their understanding that, upon their request and consistent with this part, they must be provided a list of entities to which their information has been disclosed pursuant to the general designation (see Section 2.13(d)). (ii) \[Reserved\] (5) The purpose of the disclosure. In accordance with Section 2.13(a), the disclosure must be limited to that information which is necessary to carry out the stated purpose. (6) A statement that the consent is subject to revocation at any time except to the extent that the part 2 program or other lawful holder of patient identifying information that is permitted to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose information to a third-party payer (7) The date, event, or condition upon which the consent will expire if not revoked before. This date, event, or condition must ensure that the consent will last no longer than reasonably necessary to serve the purpose for which it is provided. (8) The signature of the patient and, when required for a patient who is a minor, the signature of an individual authorized to give consent under Section 2.14; or, when required for a patient who is incompetent or deceased, the signature of an individual authorized to sign under Section 2.15. Electronic signatures are permitted to the extent that they are not prohibited by any applicable law. (9) The date on which the consent is signed.

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by an individual's 42 CFR Part 2.31 consent directive, "42CFRPart2CD" as the security label policy code.

Since information governed by an individual's 42 CFR Part 2.31 consent directive has a level of confidentiality protection that is more stringent than the normal level of protection under HIPAA 45 CFR Â§ 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, assign the HL7 Confidentiality code "R" (restricted).


Code: CompoundResearchCD
Display: Compound HIPAA Research Authorization and Informed Consent for Research
Definition:
A code representing an individual's consent directive that complies with HIPAA Privacy rule 45 CFR Section 164.508 Uses and disclosures for which an authorization is required https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf, which is a US Federal law stipulating the policy elements of a valid authorization under this Section specific to disclosures for purposes of research when combined with a Common Rule or Federal Drug Administration consent to participate in research also known as a compound authorization.

*Usage Note:* The Agency for Healthcare Research and Quality (AHRQ) has developed the Informed Consent and Authorization Toolkit for Minimal Risk Research to facilitate the process of obtaining informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization from potential research subjects. This toolkit contains information for people responsible for ensuring that potential research subjects are informed in a manner that is consistent with medical ethics and regulatory guidelines. From https://www.ahrq.gov/sites/default/files/publications/files/ictoolkit.pdf.

Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by an individual's right of access directive under 45 CFR Section 164.508 use "CompoundResearchCD" as the security label policy code.

Information or biospecimen disclosed under the Common Rule are not protected by the HIPAA Privacy Rule. If protected under other laws such as confidentiality provisions under the Common Rule, assign the HL7 Confidentiality code "M" (moderate).

See ActCode.\_ActPolicyType.\_ActPrivacyPolicy.\_ActPrivacyLaw.\_ActUSPrivacyLaw.HIPAAAuth (HIPAA Authorization for Disclosure). See: HIPAAAuth and NIH Sample Authorization Language for Research Uses and Disclosures of Individually Identifiable Health Information by a Covered Health Care Provider https://privacyruleandresearch.nih.gov/authorization.asp


Code: HIPAAAuthCD
Display: HIPAA Authorization Consent Directive
Definition:
A code representing an individual's consent directive that complies with HIPAA Privacy rule 45 CFR Section 164.508 Uses and disclosures for which an authorization is required https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf, which is a US Federal law stipulating the policy elements of a valid authorization under this Section.

An "authorization" is required by the Privacy Rule for uses and disclosures of protected health information not otherwise allowed by the Rule. Where the Privacy Rule requires patient authorization, voluntary consent is not sufficient to permit a use or disclosure of protected health information unless it also satisfies the requirements of a valid authorization. An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.

An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the information may be used or disclosed. With limited exceptions, covered entities may not condition treatment or coverage on the individual providing an authorization. https://www.hhs.gov/hipaa/for-professionals/faq/264/what-is-the-difference-between-consent-and-authorization/index.html

A HIPAA Authorization must comply with 45 CFR Section164.508(c) Implementation specifications: Core elements and requirements - (1) Core elements. A valid authorization under this Section must contain at least the following elements: (i) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion. (ii) The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure. (iii) The name or other specific identification of the person(s), or class of persons, to whom the covered entity may make the requested use or disclosure. (iv) A description of each purpose of the requested use or disclosure. The statement "at the request of the individual" is a sufficient description of the purpose when an individual initiates the authorization and does not, or elects not to, provide a statement of the purpose. (v) An expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. The statement "end of the research study," "none," or similar language is sufficient if the authorization is for a use or disclosure of protected health information for research, including for the creation and maintenance of a research database or research repository. (vi) Signature of the individual and date. If the authorization is signed by a personal representative of the individual, a description of such representative's authority to act for the individual must also be provided. (2)Required statements. In addition to the core elements, the authorization must contain statements adequate to place the individual on notice of all of the following: (i) The individual's right to revoke the authorization in writing, and either: (A) The exceptions to the right to revoke and a description of how the individual may revoke the authorization; or (B) To the extent that the information in paragraph (c)(2)(i)(A) of this section is included in the notice required by Section 164.520, a reference to the covered entity's notice. https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf

*Usage Note:* Used to indicate the legal authority for assigning security labels to HIPAA governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by a an individual's HIPAA Authorization for Disclosure, use "HIPAAAuthCD" as the security label policy code.

Information governed under a HIPAA Authorization for Disclosure has the level of confidentiality protection afforded under the 45 CFR Section 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, which is considered the "norm", assign the HL7 Confidentiality code "N" (normal).


Code: HIPAAConsentCD
Display: HIPAA Consent Directive
Definition:
A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule 45 CFR Section 164.522 Rights to request privacy protection for protected health information https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-522.pdf, which stipulates the process by which a covered entity seeks agreement from an individual regarding how it will use and disclose the individual's protected health information for treatment, payment, and health care operations is termed a "consent."

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by an individual's consent directive under 45 CFR Section 164.522 use "HIPAAConsentCD" as the security label policy code.

Since information governed by a 45 CFR Section 164.522 has a level of confidentiality protection that is more stringent than the normal level of protection under HIPAA 45 CFR Section 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, assign the HL7 Confidentiality code "R" (restricted).


Code: HIPAAResearchAuthCD
Display: HIPAA Authorization for Disclosure for Research Consent Directive
Definition:
A code representing an individual's consent directive that complies with HIPAA Privacy rule 45 CFR Section 164.508 Uses and disclosures for which an authorization is required https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf, which is a US Federal law stipulating the policy elements of a valid authorization under this Section specific to disclosures for purposes of research.

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by an individual's HIPAA Authorization for Disclosure for Research under 45 CFR Section 164.508 use "HIPAAResearchAuthCD" as the security label policy code.

Information disclosed under an individual's HIPAA Authorization for Disclosure for Research are not protected by the HIPAA Privacy Rule. If protected under other laws such as confidentiality provisions under the Common Rule, assign the HL7 Confidentiality code "M" (moderate).

See ActCode.\_ActPolicyType.\_ActPrivacyPolicy.\_ActPrivacyLaw.\_ActUSPrivacyLaw.HIPAAAuth (HIPAA Authorization for Disclosure). See: HIPAAAuth and NIH Sample Authorization Language for Research Uses and Disclosures of Individually Identifiable Health Information by a Covered Health Care Provider https://privacyruleandresearch.nih.gov/authorization.asp


Code: HIPAAROAD
Display: HIPAA Right of Access Directive
Definition:
A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule 45 CFR Section 164.524 Access of individuals to protected health information https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-524.pdf, stipulating the policy elements of an individual's written and signed right of access directive requesting that a covered entity send the individual's protected health information (PHI) to a third party.

See 45 CFR 164.524(c)(3)(ii) If an individual's request for access directs the covered entity to transmit the copy of protected health information directly to another person designated by the individual, the covered entity must provide the copy to the person designated by the individual. The individual's request must be in writing, signed by the individual, and clearly identify the designated person and where to send the copy of protected health information. https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-524.pdf

This right applies to PHI in a designated record set, which is defined as "Designated record set means: (1) A group of records maintained by or for a covered entity that is: (i) The medical records and billing records about individuals maintained by or for a covered health care provider; (ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals. \[https://www.law.cornell.edu/cfr/text/45/164.501\]. Also see HHS Individuals' Right under HIPAA to Access their Health Information 45 CFR Section 164.524 \[https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html\#maximumflatfee\].

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by an individual's right of access directive under 45 CFR Section 164.524 use "HIPAAROAD" as the security label policy code.

Information disclosed under a HIPAA 42 CFR Section 164.524 no longer has the level of confidentiality protection afforded under the 45 CFR Section 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf, which is considered the "norm", assign the HL7 Confidentiality code "M" (moderate), which may be protected under other laws such as the Federal Trade Commission privacy and security regulations.


Code: MDHHS-5515
Display: Michigan Consent to Share Behavioral Health Information for Care Coordination Purposes
Definition:
The State of Michigan standard privacy consent form for sharing of health information specific to behavioral health and substance use treatment in accordance with Public Act 129 of 2014. In Michigan, while providers are not required to use this new standard form (MDHHS-5515), they are required to accept it.

*Usage Note:* For legislative background, current MDHHS-5515 consent directive form, and provider and patient FAQs see http://www.michigan.gov/mdhhs/0,5885,7-339-71550\_2941\_58005-343686--,00.html


Code: 42CFRPart2
Display: 42 CFR Part2
Definition:
A code representing 42 CFR Part 2 Confidentiality of Substance Use Disorder Patient Records. 42 CFR Part 2 stipulates the privacy rights of an individual who has applied for or been given diagnosis or treatment for alcohol or drug abuse at a federally assisted program, which includes non-disclosure of health information relating to health care paid for by a federally assisted substance use disorder program without patient consent. https://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol1/pdf/CFR-2010-title42-vol1-part2.pdf

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, the collection, access, use, and disclosure of healthcare information is governed by 42 CFR Part 2 Confidentiality of Substance Use Disorder Patient Records https://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol1/pdf/CFR-2010-title42-vol1-part2.pdf use "42CFRPart2" as the security label policy code.

Since information governed by a 42 CFR Part 2 has a level of confidentiality protection that is more stringent than the normal level of protection under HIPAA 45 CFR Section 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf assign the HL7 Confidentiality code "R" (restricted).


Code: CommonRule
Display: Common Rule
Definition:
A code representing U.S. Federal laws governing research-related privacy policies known as the "Common Rule". The Common Rule is the U.S. Federal regulations governing the protection of human subjects in research (codified at Subpart A of 45 CFR part 46), which has been adopted by 15 U.S. Federal departments and agencies in an effort to promote uniformity, understanding, and compliance with human subject protections. Existing regulations governing the protection of human subjects in Food and Drug Administration (FDA)-regulated research (21 CFR parts 50, 56, 312, and 812) are separate from the Common Rule but include similar requirements.

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information or biospecimen is governed by the Common Rule use "COMMONRULE" as the security label policy code. Information or biospecimen disclosed under the Common Rule are not protected by the HIPAA Privacy Rule. If protected under other laws such as confidentiality provisions under the Common Rule, assign the HL7 Confidentiality code "M" (moderate).


Code: HIPAAAuth
Display: HIPAA Authorization for Disclosure
Definition:
A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR Section 164.508) Uses and disclosures for which an authorization is required https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf, which stipulates the process by which a covered entity seeks agreement from an individual to use or disclose protected health information for other purposes, or to authorize another covered entity to disclose protected health information to the requesting covered entity, are termed "authorizations".

An "authorization" is required by the Privacy Rule for uses and disclosures of protected health information not otherwise allowed by the Rule. Where the Privacy Rule requires patient authorization, voluntary consent is not sufficient to permit a use or disclosure of protected health information unless it also satisfies the requirements of a valid authorization. An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.

An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the information may be used or disclosed. With limited exceptions, covered entities may not condition treatment or coverage on the individual providing an authorization. https://www.hhs.gov/hipaa/for-professionals/faq/264/what-is-the-difference-between-consent-and-authorization/index.html

*Usage Note:* Used to indicate the legal authority for assigning security labels to HIPAA governed information. In this case, where use or disclosure of healthcare information is governed by a covered entity's HIPAA Authorization for Disclosure, use "HIPAAAuth" as the security label policy code.

Information disclosed under a HIPAA Authorization for Disclosure no longer has the level of confidentiality protection afforded under the 45 CFR Section 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf, which is considered the "norm", assign the HL7 Confidentiality code "M" (moderate), which may be protected under other laws such as the Federal Trade Commission privacy and security regulations.


Code: HIPAAConsent
Display: HIPAA Consent
Definition:
A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR Section 164.522), which stipulates the process by which a covered entity seeks agreement from an individual regarding how it will use and disclose the individual's protected health information for treatment, payment, and health care operations is termed a "consent".

The Privacy Rule permits, but does not require, a covered entity to voluntarily obtain patient consent for uses and disclosures of protected health information for treatment, payment, and health care operations. Covered entities that do so have complete discretion to design a process that best suits their needs. From https://www.hhs.gov/hipaa/for-professionals/faq/264/what-is-the-difference-between-consent-and-authorization/index.html. The provisions relating to consent are largely contained in Section 164.522 Rights to request privacy protection for protected health information https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-522.pdf.

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by 45 CFR Section 164.522 use 'HIPAAConsent' as the security label policy code.

Since information governed by a 45 CFR Section 164.522 has a level of confidentiality protection that is more stringent than the normal level of protection under HIPAA 45 CFR Section 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, assign the HL7 Confidentiality code 'R' (restricted).


Code: HIPAANOPP
Display: HIPAA notice of privacy practices
Definition:
A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR Section 164.520), which stipulates an individual's right to adequate notice of the uses and disclosures of protected health information that may be made by the covered entity, and of the individual's rights and the covered entity's legal duties with respect to protected health information. Relevant HIPAA Privacy Rule provisions are at Section 164.520 (a) Standard: Notice of privacy practices. https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-520.pdf

*Usage Note:* Used to indicate the legal authority for assigning security labels to HIPAA governed information. In this case, if collection, access, use, or disclosure of healthcare information is governed by a covered entity's HIPAA Notice of Privacy Practices, use "HIPAANOPP" as the security label policy code.

Information governed under a HIPAA Notice of Privacy Practices has the level of confidentiality protection afforded under the 45 CFR Section 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf , which is considered the "norm", assign the HL7 Confidentiality code "N" (normal).


Code: HIPAAPsyNotes
Display: HIPAA psychotherapy notes
Definition:
A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR Section 164.508), which stipulates the privacy rights of an individual who is the subject of psychotherapy notes, and requires authorization for certain uses and disclosure of that information.

Definition of Psychotherapy notes 45 CFR Section 164.501 https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-501.pdf: Psychotherapy notes means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

See Section 164.508 Uses and disclosures for which an authorization is required. (2)Authorization required: Psychotherapy notes https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf: Notwithstanding any provision of this subpart, other than the transition provisions in Section 164.532, a covered entity must obtain an authorization for any use or disclosure of psychotherapy notes, except: (i) To carry out the following treatment, payment, or health care operations: (A) Use by the originator of the psychotherapy notes for treatment; (B) Use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or (C) Use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and (ii) A use or disclosure that is required by Section 164.502(a)(2)(ii) or permitted by Section 164.512(a); Section 164.512(d) with respect to the oversight of the originator of the psychotherapy notes; Section 164.512(g)(1); Section 164.512(j)(1)(i).

*Usage Note:* Used to indicate the legal authority for assigning security labels to HIPAA governed information. In this case, the collection, access, use, or disclosure of healthcare information is governed by HIPAA 45 CFR 164.508 (2) Authorization required: Psychotherapy notes https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf , use "HIPAAPsyNotes" as the security label policy code.

Since information governed by a HIPAA 45 CFR 164.508 (2) has a level of confidentiality protection that is more stringent than the normal level of protection under 45 CFR Section 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, assign the HL7 Confidentiality code "R" (restricted).


Code: HIPAAROA
Display: HIPAA Right of Access
Definition:
A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule 45 CFR Section 164.524 Access of individuals to protected health information https://www.govinfo.gov/app/details/CFR-2017-title45-vol1/CFR-2017-title45-vol1-sec164-524, which stipulates that an individual has a right of access to inspect and obtain a copy of protected health information about the individual in a designated record set, for as long as the protected health information is maintained in the designated record set with exceptions stipulated in HIPAA Privacy Rule Section 164.524. Exceptions include psychotherapy notes and information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding.

If an individual's request for access directs the covered entity to transmit the copy of protected health information directly to another person designated by the individual, the covered entity must provide the copy to the person designated by the individual. The individual's request must be in writing, signed by the individual, and clearly identify the designated person and where to send the copy of protected health information.

For discussion on extent of right, grounds for denial, and documentation requirements see: HHS Individuals' Right under HIPAA to Access their Health Information 45 CFR Section 164.524 https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html and HHS FAQ on Right of Access vs. HIPAA Authorization https://www.hhs.gov/hipaa/for-professionals/faq/2041/why-depend-on-the-individuals-right/index.html

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed under 45 CFR Section 164.5224 use "HIPAAROA" as the security label policy code.

Information disclosed under a HIPAA 42 CFR Section 164.524 no longer has the level of confidentiality protection afforded under the 45 CFR Section 164.506 - Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-508.pdf, which is considered the "norm", assign the HL7 Confidentiality code "M" (moderate), which may be protected under other laws such as the Federal Trade Commission privacy and security regulations.


Code: HIPAASelfPay
Display: HIPAA self-pay
Definition:
A code representing 45 CFR 164.522 Rights to request privacy protection for protected health information, which is a US Federal law stipulating the privacy rights of an individual to restrict disclosure of information related to health care items or services for which the individual pays out of pocket in full to a health plan or payer.

See 45 CFR 164.522 https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-522.pdf. (vi) A covered entity must agree to the request of an individual to restrict disclosure of protected health information about the individual to a health plan if: (A) The disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (B) The protected health information pertains solely to a health care item or service for which the individual, or person other than the health plan on behalf of the individual, has paid the covered entity in full.

*Usage Note:* Used to indicate the legal authority for assigning security labels to HIPAA governed information. In this case, the collection, access, use, or disclosure of healthcare information is governed by HIPAA 45 CFR 164.522 https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-522.pdf use "HIPAASelfPay" as the security label policy code.

Since information governed by a HIPAA 45 CFR 164.522 has a level of confidentiality protection that is more stringent than the normal level of protection under 45 CFR Section 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, assign the HL7 Confidentiality code "R" (restricted).


Code: Title38Section7332
Display: Title 38 Section 7332
Definition:
A code representing Title 38 Section 7332, which is a US Federal law stipulating the privacy rights of veterans diagnosed and treated for substance use disorders, infection with the human immunodeficiency virus, or sickle cell anemia.

https://www.gpo.gov/fdsys/granule/USCODE-2011-title38/USCODE-2011-title38-partV-chap73-subchapIII-sec7332/content-detail.html . (1) Records of the identity, diagnosis, prognosis, or treatment of any patient or subject which are maintained in connection with the performance of any program or activity (including education, training, treatment, rehabilitation, or research) relating to drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus, or sickle cell anemia which is carried out by or for the Department under this title shall, except as provided in subsections (e) and (f), be confidential, and (section 5701 of this title to the contrary notwithstanding) such records may be disclosed only for the purposes and under the circumstances expressly authorized under subsection (b). (2) Paragraph (1) prohibits the disclosure to any person or entity other than the patient or subject concerned of the fact that a special written consent is required in order for such records to be disclosed. (b) (1) The content of any record referred to in subsection (a) may be disclosed by the Secretary in accordance with the prior written consent of the patient or subject with respect to whom such record is maintained, but only to such extent, under such circumstances, and for such purposes as may be allowed in regulations prescribed by the Secretary. (2) Whether or not any patient or subject, with respect to whom any given record referred to in subsection (a) is maintained, gives written consent, the content of such record may be disclosed by the Secretary as follows: (A) To medical personnel to the extent necessary to meet a bona fide medical emergency. (B) To qualified personnel for the purpose of conducting scientific research, management audits, financial audits, or program evaluation, but such personnel may not identify, directly or indirectly, any individual patient or subject in any report of such research, audit, or evaluation, or otherwise disclose patient or subject identities in any manner. (C) (i) In the case of any record which is maintained in connection with the performance of any program or activity relating to infection with the human immunodeficiency virus, to a Federal, State, or local public-health authority charged under Federal or State law with the protection of the public health, and to which Federal or State law requires disclosure of such record, if a qualified representative of such authority has made a written request that such record be provided as required pursuant to such law for a purpose authorized by such law. (ii) A person to whom a record is disclosed under this paragraph may not redisclose or use such record for a purpose other than that for which the disclosure was made. (D) If authorized by an appropriate order of a court of competent jurisdiction granted after application showing good cause therefor. In assessing good cause the court shall weigh the public interest and the need for disclosure against the injury to the patient or subject, to the physician-patient relationship, and to the treatment services. Upon the granting of such order, the court, in determining the extent to which any disclosure of all or any part of any record is necessary, shall impose appropriate safeguards against unauthorized disclosure. (E) To an entity described in paragraph (1)(B) of section 5701(k) of this title, but only to the extent authorized by such section. (F) (i) To a representative of a patient who lacks decision-making capacity, when a practitioner deems the content of the given record necessary for that representative to make an informed decision regarding the patient's treatment. (ii) In this subparagraph, the term "representative" means an individual, organization, or other body authorized under section 7331 of this title and its implementing regulations to give informed consent on behalf of a patient who lacks decision-making capacity. (G) To a State controlled substance monitoring program, including a program approved by the Secretary of Health and Human Services under section 399O of the Public Health Service Act (42 U.S.C. 280g-3), to the extent necessary to prevent misuse and diversion of prescription medicines. (H) (i) To a non-Department entity (including private entities and other Federal agencies) for purposes of providing health care, including hospital care, medical services, and extended care services, to Veterans or performing other health care-related activities or functions. (ii) An entity to which a record is disclosed under this subparagraph may not disclose or use such record for a purpose other than that for which the disclosure was made or as permitted by law. (I) To a third party in order to recover or collect reasonable charges for care furnished to, or paid on behalf of, a Veteran in connection with a non-service connected disability as permitted by section 1729 of this title or for a condition for which recovery is authorized or with respect to which the United States is deemed to be a third party beneficiary under the Act entitled 'An Act to provide for the recovery from tortiously liable third persons of the cost of hospital and medical care and treatment furnished by the United States' (Public Law 87-693; 42 U.S.C. 2651 et seq.; commonly known as the 'Federal Medical Care Recovery Act').

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by 38 U.S. Code Section 7332 - Confidentiality of certain medical records https://www.gpo.gov/fdsys/granule/USCODE-2011-title38/USCODE-2011-title38-partV-chap73-subchapIII-sec7332/content-detail.html use "Title38Section7332" as the security label policy code.

Since information governed by a Title 38 Section 7332 has a level of confidentiality protection that is more stringent than the normal level of protection under HIPAA 45 CFR Section 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, assign the HL7 Confidentiality code "R" (restricted).


Code: a) HIPAAConsent
Display: HIPAA Consent
Definition:
Code retired in December 2019 and replaced by code HIPAAConsent. Originally entered with copy/paste error in code value.

A code representing U.S. Public Law 104-191 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR Section 164.522), which stipulates the process by which a covered entity seeks agreement from an individual regarding how it will use and disclose the individual's protected health information for treatment, payment, and health care operations is termed a "consent." The Privacy Rule permits, but does not require, a covered entity to voluntarily obtain patient consent for uses and disclosures of protected health information for treatment, payment, and health care operations. Covered entities that do so have complete discretion to design a process that best suits their needs. From https://www.hhs.gov/hipaa/for-professionals/faq/264/what-is-the-difference-between-consent-and-authorization/index.html. The provisions relating to consent are largely contained in Section 164.522 Rights to request privacy protection for protected health information https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-522.pdf.

*Usage Note:* Used to indicate the legal authority for assigning security labels to governed information. In this case, where collection, access, use, or disclosure of healthcare information is governed by 45 CFR Section 164.522 use "HIPAAConsent" as the security label policy code.

Since information governed by a 45 CFR Section 164.522 has a level of confidentiality protection that is more stringent than the normal level of protection under HIPAA 45 CFR Section 164.506 Uses and disclosures to carry out treatment, payment, or health care operations https://www.gpo.gov/fdsys/pkg/CFR-2017-title45-vol1/pdf/CFR-2017-title45-vol1-sec164-506.pdf, assign the HL7 Confidentiality code "R" (restricted).


Code: USResearchInformedAssent
Display: Informed Assent for Research
Definition:
An informed assertion by a minor who is a candidate research subject, of the individual's willingness to participate in research. Assent means a child's affirmative agreement to participate in a clinical investigation. Mere failure to object should not, absent affirmative agreement, be construed as assent. The minor's assent must be accompanied by parental or guardian consent that the minor participate in a specified research. The assent is not legally binding, however, the accompanying consent is legally binding. Background: In the US, informed assent is governed under 21 CFR Part 50, Subpart D - Additional Safeguards for Children in Clinical Investigations. Available at https://www.law.cornell.edu/cfr/text/21/part-50/subpart-D


Code: USResearchInformedConsent
Display: Informed Consent for Research
Definition:
An informed assertion by an adult, or the parent/guardian of a minor who is a candidate research subject, of the individual's willingness to participate in a specified research study. The consent is legally binding. Background: In the US, informed assent is governed under 49 CFR § 11.116 - General Requirements for Informed Consent. Available at https://www.law.cornell.edu/cfr/text/49/11.116


Code: USBroadResearchConsent
Display: Broad Consent for Research
Definition:
An informed assertion by an adult, or the parent/guardian of a minor who is a candidate research subject, of the individual's willingness to participate in unspecified research studies, including storage, maintenance, and secondary research use of identifiable biospecimens and data.  If broad consent is obtained, any subsequent storage, maintenance, and secondary research uses of the individual’s identifiable biospecimens and data consistent with the broad consent would not require additional consent, so long as additional conditions are met, including limited review by an IRB. The consent is legally binding. Background: In the US, informed assent is governed under 49 CFR § 11.116 - General Requirements for Informed Consent. Available at https://www.law.cornell.edu/cfr/text/49/11.116


Code: DACT
Display: drug action detected issue
Definition:
**Description:**Proposed therapy may be contraindicated or ineffective based on an existing or recent drug therapy.


Code: TIME
Display: timing detected issue
Definition:
**Description:**Proposed therapy may be inappropriate or ineffective based on the proposed start or end time.


Code: PREVINEF
Display: previously ineffective
Definition:
**Definition:**The same or similar treatment has previously been attempted with the patient without achieving a positive effect.


Code: EMAUTH
Display: emergency authorization override
Definition:
Used to temporarily override normal authorization rules to gain access to data in a case of emergency. Use of this override code will typically be monitored, and a procedure to verify its proper use may be triggered when used.


Code: AIRTRNS
Display: airborne transmission
Definition:
Communication of an agent from a living subject or environmental source to a living subject through indirect contact via oral or nasal inhalation.


Code: BDYFLDTRNS
Display: body fluid contact transmission
Definition:
Communication of an agent from one living subject to another living subject through direct contact with any body fluid.


Code: BLDTRNS
Display: blood borne transmission
Definition:
Communication of an agent to a living subject through direct contact with blood or blood products whether the contact with blood is part of a therapeutic procedure or not.


Code: DERMTRNS
Display: transdermal transmission
Definition:
Communication of an agent from a living subject or environmental source to a living subject via agent migration through intact skin.


Code: ENVTRNS
Display: environmental exposure transmission
Definition:
Communication of an agent from an environmental surface or source to a living subject by direct contact.


Code: FECTRNS
Display: fecal-oral transmission
Definition:
Communication of an agent from a living subject or environmental source to a living subject through oral contact with material contaminated by person or animal fecal material.


Code: LACTTRNS
Display: lactation transmission
Definition:
Communication of an agent from one living subject to another living subject through direct contact with mammalian milk or colostrum.


Code: NOSTRNS
Display: nosocomial transmission
Definition:
Communication of an agent from any entity to a living subject while the living subject is in the patient role in a healthcare facility.


Code: PARTRNS
Display: parenteral transmission
Definition:
Communication of an agent from a living subject or environmental source to a living subject where the acquisition of the agent is not via the alimentary canal.


Code: PLACTRNS
Display: transplacental transmission
Definition:
Communication of an agent from a living subject to the progeny of that living subject via agent migration across the maternal-fetal placental membranes while in utero.


Code: SEXTRNS
Display: sexual transmission
Definition:
Communication of an agent from one living subject to another living subject through direct contact with genital or oral tissues as part of a sexual act.


Code: TRNSFTRNS
Display: transfusion transmission
Definition:
Communication of an agent from one living subject to another living subject through direct contact with blood or blood products where the contact with blood is part of a therapeutic procedure.


Code: VECTRNS
Display: vector-borne transmission
Definition:
Communication of an agent from a living subject acting as a required intermediary in the agent transmission process to a recipient living subject via direct contact.


Code: WATTRNS
Display: water-borne transmission
Definition:
Communication of an agent from a contaminated water source to a living subject whether the water is ingested as a food or not. The route of entry of the water may be through any bodily orifice.


Code: REPRESENTATIVE_BEAT
Display: ECG representative beat waveforms
Definition:
This Observation Series type contains waveforms of a "representative beat" (a.k.a. "median beat" or "average beat"). The waveform samples are measured in relative time, relative to the beginning of the beat as defined by the Observation Series effective time. The waveforms are not directly acquired from the subject, but rather algorithmically derived from the "rhythm" waveforms.


Code: RHYTHM
Display: ECG rhythm waveforms
Definition:
This Observation type contains ECG "rhythm" waveforms. The waveform samples are measured in absolute time (a.k.a. "subject time" or "effective time"). These waveforms are usually "raw" with some minimal amount of noise reduction and baseline filtering applied.


Code: DEMO
Display: all demographic information sensitivity
Definition:
Policy for handling all demographic information about an information subject, which will be afforded heightened confidentiality. Policies may govern sensitivity of information related to all demographic about an information subject, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: DOB
Display: date of birth information sensitivity
Definition:
Policy for handling information related to an information subject's date of birth, which will be afforded heightened confidentiality.Policies may govern sensitivity of information related to an information subject's date of birth, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: GENDER
Display: gender and sexual orientation information sensitivity
Definition:
Policy for handling information related to an information subject's gender and sexual orientation, which will be afforded heightened confidentiality. Policies may govern sensitivity of information related to an information subject's gender and sexual orientation, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: LIVARG
Display: living arrangement information sensitivity
Definition:
Policy for handling information related to an information subject's living arrangement, which will be afforded heightened confidentiality. Policies may govern sensitivity of information related to an information subject's living arrangement, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: MARST
Display: marital status information sensitivity
Definition:
Policy for handling information related to an information subject's marital status, which will be afforded heightened confidentiality. Policies may govern sensitivity of information related to an information subject's marital status, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: PATLOC
Display: patient location
Definition:
Policy for handling information related to an individual's location, which is deemed sensitive when the disclosure could impact the privacy, well-being, or safety of that subject, and requires additional protection.

*Usage Note:* If there is a jurisdictional, organizational, or individual mandate, then use the applicable ActPrivacyLaw or ActConsentDirective code from the ActCode system to and specify the law in addition to this more generic code.


Code: RACE
Display: race information sensitivity
Definition:
Policy for handling information related to an information subject's race, which will be afforded heightened confidentiality. Policies may govern sensitivity of information related to an information subject's race, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: REL
Display: religion information sensitivity
Definition:
Policy for handling information related to an information subject's religious affiliation, which will be afforded heightened confidentiality. Policies may govern sensitivity of information related to an information subject's religion, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Notes:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: GENE
Display: gene
Definition:
**Description:** A DNA segment that contributes to phenotype/function. In the absence of demonstrated function a gene may be characterized by sequence, transcription or homology


Code: I
Display: Isolation
Definition:
Accommodations used in the care of diseases that are transmitted through casual contact or respiratory transmission.


Code: S
Display: Suite
Definition:
Uniquely designed and elegantly decorated accommodations with many amenities available for an additional charge.


Code: _SubstanceAdministrationActCode
Display: SubstanceAdministrationActCode
Definition:
The specific chemical or radiological substance administered or to be administered into the body for therapeutic effect.


Code: PAT_ADV_EVNT
Display: patient adverse event
Definition:
Indicates that the ICSR is describing problems that a patient experienced after receiving a vaccine product.


Code: VAC_PROBLEM
Display: vaccine product problem
Definition:
Indicates that the ICSR is describing a problem with the actual vaccine product such as physical defects (cloudy, particulate matter) or inability to confer immunity.


Code: _EntitySensitivityPolicyType
Display: EntityInformationSensitivityPolicy
Definition:
Types of sensitivity policies that may apply to a sensitive attribute on an Entity.

*Usage Note:* EntitySensitivity codes are used to convey a policy that is applicable to sensitive information conveyed by an entity attribute. May be used to bind a Role.confidentialityCode associated with an Entity per organizational policy. Role.confidentialityCode is defined in the RIM as "an indication of the appropriate disclosure of information about this Role with respect to the playing Entity."


Code: _RoleInformationSensitivityPolicy
Display: RoleInformationSensitivityPolicy
Definition:
Types of sensitivity policies that apply to Roles.

*Usage Notes:* RoleSensitivity codes are used to bind information to a Role.confidentialityCode per organizational policy. Role.confidentialityCode is defined in the RIM as "an indication of the appropriate disclosure of information about this Role with respect to the playing Entity."


Code: ADOL
Display: adolescent information sensitivity
Definition:
Policy for handling information related to an adolescent, which will be afforded heightened confidentiality per applicable organizational or jurisdictional policy. An enterprise may have a policy that requires that adolescent patient information be provided heightened confidentiality. Information deemed sensitive typically includes health information and patient role information including patient status, demographics, next of kin, and location.

*Usage Note:* For use within an enterprise in which an adolescent is the information subject. If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: CEL
Display: celebrity information sensitivity
Definition:
Policy for handling information related to a celebrity (people of public interest (VIP), which will be afforded heightened confidentiality. Celebrities are people of public interest (VIP) about whose information an enterprise may have a policy that requires heightened confidentiality. Information deemed sensitive may include health information and patient role information including patient status, demographics, next of kin, and location.

*Usage Note:*  For use within an enterprise in which the information subject is deemed a celebrity or very important person. If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: DIA
Display: diagnosis information sensitivity
Definition:
Policy for handling information related to a diagnosis, health condition or health problem, which will be afforded heightened confidentiality. Diagnostic, health condition or health problem related information may be deemed sensitive by organizational policy, and require heightened confidentiality.

*Usage Note:* For use within an enterprise that provides heightened confidentiality to diagnostic, health condition or health problem related information deemed sensitive. If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: DRGIS
Display: drug information sensitivity
Definition:
Policy for handling information related to a drug, which will be afforded heightened confidentiality. Drug information may be deemed sensitive by organizational policy, and require heightened confidentiality.

*Usage Note:* For use within an enterprise that provides heightened confidentiality to drug information deemed sensitive. If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: EMP
Display: employee information sensitivity
Definition:
Policy for handling information related to an employee, which will be afforded heightened confidentiality. When a patient is an employee, an enterprise may have a policy that requires heightened confidentiality. Information deemed sensitive typically includes health information and patient role information including patient status, demographics, next of kin, and location.

*Usage Note:* Policy for handling information related to an employee, which will be afforded heightened confidentiality. Description: When a patient is an employee, an enterprise may have a policy that requires heightened confidentiality. Information deemed sensitive typically includes health information and patient role information including patient status, demographics, next of kin, and location.


Code: PDS
Display: patient default information sensitivity
Definition:
Policy for specially protecting information reported by or about a patient, which is deemed sensitive within the enterprise (i.e., by default regardless of whether the patient requested that the information be deemed sensitive for another reason.) For example information reported by the patient about another person, e.g., a family member, may be deemed sensitive by default. Organizational policy may allow the sensitivity tag to be cleared on patient's request.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law in addition to this more generic code.

For example, VA deems employee information sensitive by default. Information about a patient who is being stalked or a victim of abuse or violence may be deemed sensitive by default per a provider organization's policies.


Code: PHY
Display: physician requested information sensitivity
Definition:
Policy for handling information about a patient, which a physician or other licensed healthcare provider deems sensitive. Once tagged by the provider, this may trigger alerts for follow up actions according to organizational policy or jurisdictional law.

*Usage Note:* For use within an enterprise that provides heightened confidentiality to certain types of information designated by a physician as sensitive. If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.

Use cases in which this code could be used are, e.g., in systems that lack the ability to automatically detect sensitive information and must rely on manual tagging; a system that lacks an applicable sensitivity tag, or for ad hoc situations where criticality of the situation requires that the tagging be done immediately by the provider before coding or transcription of consult notes can be completed, e.g., upon detection of a patient with suicidal tendencies or potential for violence.


Code: PRS
Display: patient requested information sensitivity
Definition:
Policy for specially protecting information reported by or about a patient, which the patient deems sensitive, and the patient requests that collection, access, use, or disclosure of that information be restricted. For example, a minor patient may request that information about reproductive health not be disclosed to the patient's family or to particular providers and payers.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: ADNFPPELAT
Display: adjud. nullified prior-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.


Code: ADNFPPELCT
Display: adjud. nullified prior-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted electronically.


Code: ADNFPPMNAT
Display: adjud. nullified prior-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.


Code: ADNFPPMNCT
Display: adjud. nullified prior-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.


Code: ADNFSPELAT
Display: adjud. nullified same-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently nullified in the specified period and submitted electronically.


Code: ADNFSPELCT
Display: adjud. nullified same-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently nullified in the specified period and submitted electronically.


Code: ADNFSPMNAT
Display: adjud. nullified same-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.


Code: ADNFSPMNCT
Display: adjud. nullified same-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date), subsequently cancelled in the specified period and submitted manually.


Code: ADNPPPELAT
Display: adjud. non-payee payable prior-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: ADNPPPELCT
Display: adjud. non-payee payable prior-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: ADNPPPMNAT
Display: adjud. non-payee payable prior-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: ADNPPPMNCT
Display: adjud. non-payee payable prior-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: ADNPSPELAT
Display: adjud. non-payee payable same-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: ADNPSPELCT
Display: adjud. non-payee payable same-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: ADNPSPMNAT
Display: adjud. non-payee payable same-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: ADNPSPMNCT
Display: adjud. non-payee payable same-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: ADPPPPELAT
Display: adjud. payee payable prior-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: ADPPPPELCT
Display: adjud. payee payable prior-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: ADPPPPMNAT
Display: adjud. payee payable prior-period manual amout
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: ADPPPPMNCT
Display: adjud. payee payable prior-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable prior to the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: ADPPSPELAT
Display: adjud. payee payable same-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: ADPPSPELCT
Display: adjud. payee payable same-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: ADPPSPMNAT
Display: adjud. payee payable same-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: ADPPSPMNCT
Display: adjud. payee payable same-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as payable during the specified time period (based on adjudication date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: ADRFPPELAT
Display: adjud. refused prior-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted electronically.


Code: ADRFPPELCT
Display: adjud. refused prior-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted electronically.


Code: ADRFPPMNAT
Display: adjud. refused prior-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted manually.


Code: ADRFPPMNCT
Display: adjud. refused prior-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as refused prior to the specified time period (based on adjudication date) and submitted manually.


Code: ADRFSPELAT
Display: adjud. refused same-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted electronically.


Code: ADRFSPELCT
Display: adjud. refused same-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted electronically.


Code: ADRFSPMNAT
Display: adjud. refused same-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted manually.


Code: ADRFSPMNCT
Display: adjud. refused same-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were adjudicated as refused during the specified time period (based on adjudication date) and submitted manually.


Code: PDNFPPELAT
Display: paid nullified prior-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted electronically.


Code: PDNFPPELCT
Display: paid nullified prior-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted electronically.


Code: PDNFPPMNAT
Display: paid nullified prior-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.


Code: PDNFPPMNCT
Display: paid nullified prior-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.


Code: PDNFSPELAT
Display: paid nullified same-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently nullified in the specified period and submitted electronically.


Code: PDNFSPELCT
Display: paid nullified same-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently cancelled in the specified period and submitted electronically.


Code: PDNFSPMNAT
Display: paid nullified same-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.


Code: PDNFSPMNCT
Display: paid nullified same-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date), subsequently nullified in the specified period and submitted manually.


Code: PDNPPPELAT
Display: paid non-payee payable prior-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: PDNPPPELCT
Display: paid non-payee payable prior-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: PDNPPPMNAT
Display: paid non-payee payable prior-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: PDNPPPMNCT
Display: paid non-payee payable prior-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: PDNPSPELAT
Display: paid non-payee payable same-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: PDNPSPELCT
Display: paid non-payee payable same-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted electronically.


Code: PDNPSPMNAT
Display: paid non-payee payable same-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: PDNPSPMNCT
Display: paid non-payee payable same-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that do not match a specified payee (e.g. pay patient) and submitted manually.


Code: PDPPPPELAT
Display: paid payee payable prior-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: PDPPPPELCT
Display: paid payee payable prior-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: PDPPPPMNAT
Display: paid payee payable prior-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: PDPPPPMNCT
Display: paid payee payable prior-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were paid prior to the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: PDPPSPELAT
Display: paid payee payable same-period electronic amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: PDPPSPELCT
Display: paid payee payable same-period electronic count
Definition:
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted electronically.


Code: PDPPSPMNAT
Display: paid payee payable same-period manual amount
Definition:
Identifies the total net amount of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: PDPPSPMNCT
Display: paid payee payable same-period manual count
Definition:
Identifies the total number of all Invoice Groupings that were paid during the specified time period (based on payment date) that match a specified payee (e.g. pay provider) and submitted manually.


Code: SBBLELAT
Display: submitted billed electronic amount
Definition:
Identifies the total net amount billed for all submitted Invoice Groupings within a time period and submitted electronically. Adjudicated invoice elements are included.


Code: SBBLELCT
Display: submitted billed electronic count
Definition:
Identifies the total number of submitted Invoice Groupings within a time period and submitted electronically. Adjudicated invoice elements are included.


Code: SBNFELAT
Display: submitted nullified electronic amount
Definition:
Identifies the total net amount billed for all submitted Invoice Groupings that were nullified within a time period and submitted electronically. Adjudicated invoice elements are included.


Code: SBNFELCT
Display: submitted cancelled electronic count
Definition:
Identifies the total number of submitted Invoice Groupings that were nullified within a time period and submitted electronically. Adjudicated invoice elements are included.


Code: SBPDELAT
Display: submitted pending electronic amount
Definition:
Identifies the total net amount billed for all submitted Invoice Groupings that are pended or held by the payor, within a time period and submitted electronically. Adjudicated invoice elements are not included.


Code: SBPDELCT
Display: submitted pending electronic count
Definition:
Identifies the total number of submitted Invoice Groupings that are pended or held by the payor, within a time period and submitted electronically. Adjudicated invoice elements are not included.


Code: REP_HALF_LIFE
Display: representative half-life
Definition:
**Description:**This observation represents an 'average' or 'expected' half-life typical of the product.


Code: SPLCOATING
Display: coating
Definition:
**Definition:** A characteristic of an oral solid dosage form of a medicinal product, indicating whether it has one or more coatings such as sugar coating, film coating, or enteric coating. Only coatings to the external surface or the dosage form should be considered (for example, coatings to individual pellets or granules inside a capsule or tablet are excluded from consideration).

**Constraints:** The Observation.value must be a Boolean (BL) with true for the presence or false for the absence of one or more coatings on a solid dosage form.


Code: SPLCOLOR
Display: color
Definition:
**Definition:** A characteristic of an oral solid dosage form of a medicinal product, specifying the color or colors that most predominantly define the appearance of the dose form. SPLCOLOR is not an FDA specification for the actual color of solid dosage forms or the names of colors that can appear in labeling.

**Constraints:** The Observation.value must be a single coded value or a list of multiple coded values, specifying one or more distinct colors that approximate of the color(s) of distinct areas of the solid dosage form, such as the different sides of a tablet or one-part capsule, or the different halves of a two-part capsule. Bands on banded capsules, regardless of the color, are not considered when assigning an SPLCOLOR. Imprints on the dosage form, regardless of their color are not considered when assigning an SPLCOLOR. If more than one color exists on a particular side or half, then the most predominant color on that side or half is recorded. If the gelatin capsule shell is colorless and transparent, use the predominant color of the contents that appears through the colorless and transparent capsule shell. Colors can include: Black;Gray;White;Red;Pink;Purple;Green;Yellow;Orange;Brown;Blue;Turquoise.


Code: SPLIMAGE
Display: image
Definition:
**Description:** A characteristic representing a single file reference that contains two or more views of the same dosage form of the product; in most cases this should represent front and back views of the dosage form, but occasionally additional views might be needed in order to capture all of the important physical characteristics of the dosage form. Any imprint and/or symbol should be clearly identifiable, and the viewer should not normally need to rotate the image in order to read it. Images that are submitted with SPL should be included in the same directory as the SPL file.


Code: SPLIMPRINT
Display: imprint
Definition:
**Definition:** A characteristic of an oral solid dosage form of a medicinal product, specifying the alphanumeric text that appears on the solid dosage form, including text that is embossed, debossed, engraved or printed with ink. The presence of other non-textual distinguishing marks or symbols is recorded by SPLSYMBOL.

**Examples:** Included in SPLIMPRINT are alphanumeric text that appears on the bands of banded capsules and logos and other symbols that can be interpreted as letters or numbers.

**Constraints:** The Observation.value must be of type Character String (ST). Excluded from SPLIMPRINT are internal and external cut-outs in the form of alphanumeric text and the letter 'R' with a circle around it (when referring to a registered trademark) and the letters 'TM' (when referring to a 'trade mark'). To record text, begin on either side or part of the dosage form. Start at the top left and progress as one would normally read a book. Enter a semicolon to show separation between words or line divisions.


Code: SPLSCORING
Display: scoring
Definition:
**Definition:** A characteristic of an oral solid dosage form of a medicinal product, specifying the number of equal pieces that the solid dosage form can be divided into using score line(s).

**Example:** One score line creating two equal pieces is given a value of 2, two parallel score lines creating three equal pieces is given a value of 3.

**Constraints:** Whether three parallel score lines create four equal pieces or two intersecting score lines create two equal pieces using one score line and four equal pieces using both score lines, both have the scoring value of 4. Solid dosage forms that are not scored are given a value of 1. Solid dosage forms that can only be divided into unequal pieces are given a null-value with nullFlavor other (OTH).


Code: SPLSHAPE
Display: shape
Definition:
**Description:** A characteristic of an oral solid dosage form of a medicinal product, specifying the two dimensional representation of the solid dose form, in terms of the outside perimeter of a solid dosage form when the dosage form, resting on a flat surface, is viewed from directly above, including slight rounding of corners. SPLSHAPE does not include embossing, scoring, debossing, or internal cut-outs. SPLSHAPE is independent of the orientation of the imprint and logo. Shapes can include: Triangle (3 sided); Square; Round; Semicircle; Pentagon (5 sided); Diamond; Double circle; Bullet; Hexagon (6 sided); Rectangle; Gear; Capsule; Heptagon (7 sided); Trapezoid; Oval; Clover; Octagon (8 sided); Tear; Freeform.


Code: SPLSIZE
Display: size
Definition:
**Definition:** A characteristic of an oral solid dosage form of a medicinal product, specifying the longest single dimension of the solid dosage form as a physical quantity in the dimension of length (e.g., 3 mm). The length is should be specified in millimeters and should be rounded to the nearest whole millimeter.

**Example:** SPLSIZE for a rectangular shaped tablet is the length and SPLSIZE for a round shaped tablet is the diameter.


Code: SPLSYMBOL
Display: symbol
Definition:
**Definition:** A characteristic of an oral solid dosage form of a medicinal product, to describe whether or not the medicinal product has a mark or symbol appearing on it for easy and definite recognition. Score lines, letters, numbers, and internal and external cut-outs are not considered marks or symbols. See SPLSCORING and SPLIMPRINT for these characteristics.

**Constraints:** The Observation.value must be a Boolean (BL) with <u>true</u> indicating the presence and <u>false</u> for the absence of marks or symbols.

**Example:**


Code: ADMDX
Display: admitting diagnosis
Definition:
Admitting diagnosis are the diagnoses documented for administrative purposes as the basis for a hospital admission.


Code: DISDX
Display: discharge diagnosis
Definition:
Discharge diagnosis are the diagnoses documented for administrative purposes as the time of hospital discharge.


Code: INTDX
Display: intermediate diagnosis
Definition:
Intermediate diagnoses are those diagnoses documented for administrative purposes during the course of a hospital stay.


Code: AGGREGATE
Display: aggregate measure observation
Definition:
Indicates that the observation is carrying out an aggregation calculation, contained in the value element.


Code: CMPMSRMTH
Display: composite measure method
Definition:
Indicates what method is used in a quality measure to combine the component measure results included in an composite measure.


Code: CMPMSRSCRWGHT
Display: component measure scoring weight
Definition:
An attribute of a quality measure describing the weight this component measure score is to carry in determining the overall composite measure final score. The value is real value greater than 0 and less than 1.0. Each component measure score will be multiplied by its CMPMSRSCRWGHT and then summed with the other component measures to determine the final overall composite measure score. The sum across all CMPMSRSCRWGHT values within a single composite measure SHALL be 1.0. The value assigned is scoped to the composite measure referencing this component measure only.


Code: GUIDE
Display: guidance
Definition:
Used to allow measure developers to provide additional guidance for implementers to understand greater specificity than could be provided in the logic for data criteria.


Code: IDUR
Display: improvement notation
Definition:
Information on whether an increase or decrease in score is the preferred result (e.g., a higher score indicates better quality OR a lower score indicates better quality OR quality is within a range).


Code: MSRADJ
Display: risk adjustment
Definition:
The method of adjusting for clinical severity and conditions present at the start of care that can influence patient outcomes for making valid comparisons of outcome measures across providers. Indicates whether an eMeasure is subject to the statistical process for reducing, removing, or clarifying the influences of confounding factors to allow more useful comparisons.


Code: MSRAGG
Display: rate aggregation
Definition:
Describes how to combine information calculated based on logic in each of several populations into one summarized result. It can also be used to describe how to risk adjust the data based on supplemental data elements described in the eMeasure. (e.g., pneumonia hospital measures antibiotic selection in the ICU versus non-ICU and then the roll-up of the two).

*Open Issue:* The description does NOT align well with the definition used in the HQMF specfication; correct the MSGAGG definition, and the possible distinction of MSRAGG as a child of AGGREGATE.


Code: MSRIMPROV
Display: health quality measure improvement notation
Definition:
Information on whether an increase or decrease in score is the preferred result. This should reflect information on which way is better, an increase or decrease in score.


Code: MSRRPTTIME
Display: timeframe for reporting
Definition:
The maximum time that may elapse following completion of the measure until the measure report must be sent to the receiver.


Code: MSRSCORE
Display: measure scoring
Definition:
Indicates how the calculation is performed for the eMeasure (e.g., proportion, continuous variable, ratio)


Code: MSRSET
Display: health quality measure care setting
Definition:
Location(s) in which care being measured is rendered

Usage Note: MSRSET is used rather than RoleCode because the setting applies to what is being measured, as opposed to participating directly in the health quality measure documantion itself).


Code: MSRTYPE
Display: measure type
Definition:
Indicates whether the eMeasure is used to examine a process or an outcome over time (e.g., Structure, Process, Outcome).


Code: RAT
Display: rationale
Definition:
Succinct statement of the need for the measure. Usually includes statements pertaining to Importance criterion: impact, gap in care and evidence.


Code: REF
Display: reference
Definition:
Identifies bibliographic citations or references to clinical practice guidelines, sources of evidence, or other relevant materials supporting the intent and rationale of the eMeasure.


Code: SDE
Display: supplemental data elements
Definition:
Comparison of results across strata can be used to show where disparities exist or where there is a need to expose differences in results. For example, Centers for Medicare & Medicaid Services (CMS) in the U.S. defines four required Supplemental Data Elements (payer, ethnicity, race, and gender), which are variables used to aggregate data into various subgroups. Additional supplemental data elements required for risk adjustment or other purposes of data aggregation can be included in the Supplemental Data Element section.


Code: STRAT
Display: stratification
Definition:
Describes the strata for which the measure is to be evaluated. There are three examples of reasons for stratification based on existing work. These include: (1) evaluate the measure based on different age groupings within the population described in the measure (e.g., evaluate the whole \[age 14-25\] and each sub-stratum \[14-19\] and \[20-25\]); (2) evaluate the eMeasure based on either a specific condition, a specific discharge location, or both; (3) evaluate the eMeasure based on different locations within a facility (e.g., evaluate the overall rate for all intensive care units and also some strata include additional findings \[specific birth weights for neonatal intensive care units\]).


Code: TRANF
Display: transmission format
Definition:
Can be a URL or hyperlinks that link to the transmission formats that are specified for a particular reporting program.


Code: TIME_ABSOLUTE
Display: absolute time sequence
Definition:
A sequence of values in the "absolute" time domain. This is the same time domain that all HL7 timestamps use. It is time as measured by the Gregorian calendar


Code: TIME_RELATIVE
Display: relative time sequence
Definition:
A sequence of values in a "relative" time domain. The time is measured relative to the earliest effective time in the Observation Series containing this sequence.


Code: _IndividualCaseSafetyReportType
Display: Individual Case Safety Report Type
Definition:
A code that is used to indicate the type of case safety report received from sender. The current code example reference is from the International Conference on Harmonisation (ICH) Expert Workgroup guideline on Clinical Safety Data Management: Data Elements for Transmission of Individual Case Safety Reports. The unknown/unavailable option allows the transmission of information from a secondary sender where the initial sender did not specify the type of report.

Example concepts include: Spontaneous, Report from study, Other.


Code: ADVERSE_REACTION
Display: Adverse Reaction
Definition:
Indicates that the observation is of an unexpected negative occurrence in the subject suspected to result from the subject's exposure to one or more agents. Observation values would be the symptom resulting from the reaction.


Code: ASSERTION
Display: Assertion
Definition:
**Description:**Refines classCode OBS to indicate an observation in which observation.value contains a finding or other nominalized statement, where the encoded information in Observation.value is not altered by Observation.code. For instance, observation.code="ASSERTION" and observation.value="fracture of femur present" is an assertion of a clinical finding of femur fracture.


Code: CASESER
Display: case seriousness criteria
Definition:
**Definition:**An observation that provides a characterization of the level of harm to an investigation subject as a result of a reaction or event.


Code: CDIO
Display: case disease imported observation
Definition:
An observation that states whether the disease was likely acquired outside the jurisdiction of observation, and if so, the nature of the inter-jurisdictional relationship.

**OpenIssue:** This code could be moved to LOINC if it can be done before there are significant implemenations using it.


Code: CRIT
Display: criticality
Definition:
A clinical judgment as to the worst case result of a future exposure (including substance administration). When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality.


Code: CTMO
Display: case transmission mode observation
Definition:
An observation that states the mechanism by which disease was acquired by the living subject involved in the public health case.

**OpenIssue:** This code could be moved to LOINC if it can be done before there are significant implemenations using it.


Code: DX
Display: ObservationDiagnosisTypes
Definition:
Includes all codes defining types of indications such as diagnosis, symptom and other indications such as contrast agents for lab tests.


Code: HHOBS
Display: household situation observation
Definition:
Indicates that the observation is of a person’s living situation in a household including the household composition and circumstances.


Code: ISSUE
Display: detected issue
Definition:
There is a clinical issue for the therapy that makes continuation of the therapy inappropriate.

*Open Issue:* The definition of this code does not correctly represent the concept space of its specializations (children)


Code: _ActPrivilegeCategorizationType
Display: ActPrivilegeCategorizationType
Definition:
This domain includes observations used to characterize a privilege, under which this additional information is classified.

*Examples:*A privilege to prescribe drugs has a RESTRICTION that excludes prescribing narcotics; a surgical procedure privilege has a PRE-CONDITION that it requires prior Board approval.


Code: _AdverseSubstanceAdministrationEventActionTakenType
Display: AdverseSubstanceAdministrationEventActionTakenType
Definition:
**Definition:** Indicates the class of actions taken with regard to a substance administration related adverse event. This characterization offers a judgment of the practitioner's response to the patient's problem.

**Examples:** Example values include dose withdrawn, dose reduced, dose not changed.

**NOTE:** The concept domain is currently supported by a value set created by the International Conference on Harmonization


Code: _ObservationAllergyTestCode
Display: observation allergy test
Definition:
**Description:**Dianostic procedures ordered or performed to evaluate whether a sensitivity to a substance is present. This test may be associated with specimen collection and/or substance administration challenge actiivities.

**Example:**Skin tests and eosinophilia evaluations.


Code: _ObservationAllergyTestType
Display: ObservationAllergyTestType
Definition:
Indicates the type of allergy test performed or to be performed. E.g. the specific antibody or skin test performed


Code: _ObservationCausalityAssessmentType
Display: observation causality assessment
Definition:
**Description:**A kind of observation that allows a Secondary Observation (source act) to assert (at various levels of probability) that the target act of the association (which may be of any type of act) is implicated in the etiology of another observation that is named as the subject of the Secondary Observation

**Example:**Causality assertions where an accident is the cause of a symptom; predisposition assertions where the genetic state plus environmental factors are implicated in the development of a disease; reaction assertions where a substance exposure is associated with a finding of wheezing.


Code: _ObservationDosageDefinitionPreconditionType
Display: observation dosage definition precondition type
Definition:
**Definition:**

The set of observation type concepts that can be used to express pre-conditions to a particular dosage definition.

Rationale: Used to constrain the set of observations to those related to the applicability of a dosage, such as height, weight, age, pregnancy, liver function, kidney function, etc. For example, in drug master-file type records indicating when a specified dose is applicable.


Code: _ObservationIndicationType
Display: ObservationIndicationType
Definition:
Includes all codes defining types of indications such as diagnosis, symptom and other indications such as contrast agents for lab tests


Code: _ObservationIssueTriggerMeasuredObservationType
Display: ObservationIssueTriggerMeasuredObservationType
Definition:
Distinguishes between the kinds of measurable observations that could be the trigger for clinical issue detection. Measurable observation types include: Lab Results, Height, Weight.


Code: _ObservationQueryMatchType
Display: ObservationQueryMatchType
Definition:
**Definition:** An observation related to a query response.

**Example:**The degree of match or match weight returned by a matching algorithm in a response to a query.


Code: _PatientCharacteristicObservationType
Display: PatientCharacteristicObservationType
Definition:
Indicates the type of characteristics a patient should have for a given therapy to be appropriate. E.g. Weight, Age, certain lab values, etc.


Code: _SimpleMeasurableClinicalObservationType
Display: SimpleMeasurableClinicalObservationType
Definition:
Types of measurement observations typically performed in a clinical (non-lab) setting. E.g. Height, Weight, Blood-pressure


Code: SCHLDIV
Display: school division
Definition:
**Description:** The school division or district associated with the patient during the immunization event.


Code: DENEX
Display: denominator exclusions
Definition:
Criteria which specify subjects who should be removed from the eMeasure population and denominator before determining if numerator criteria are met. Denominator exclusions are used in proportion and ratio measures to help narrow the denominator.


Code: DENEXCEP
Display: denominator exceptions
Definition:
Criteria which specify the removal of a subject, procedure or unit of measurement from the denominator, only if the numerator criteria are not met. Denominator exceptions allow for adjustment of the calculated score for those providers with higher risk populations. Denominator exceptions are used only in proportion eMeasures. They are not appropriate for ratio or continuous variable eMeasures. Denominator exceptions allow for the exercise of clinical judgment and should be specifically defined where capturing the information in a structured manner fits the clinical workflow. Generic denominator exception reasons used in proportion eMeasures fall into three general categories:

 *  Medical reasons
 *  Patient (or subject) reasons
 *  System reasons


Code: DENOM
Display: denominator
Definition:
Criteria for specifying the entities to be evaluated by a specific quality measure, based on a shared common set of characteristics (within a specific measurement set to which a given measure belongs). The denominator can be the same as the initial population, or it may be a subset of the initial population to further constrain it for the purpose of the eMeasure. Different measures within an eMeasure set may have different denominators. Continuous Variable eMeasures do not have a denominator, but instead define a measure population.


Code: IPOP
Display: initial population
Definition:
Criteria for specifying the entities to be evaluated by a specific quality measure, based on a shared common set of characteristics (within a specific measurement set to which a given measure belongs).


Code: MSROBS
Display: measure observation
Definition:
Defines the observation to be performed for each patient or event in the measure population. Measure observations for each case in the population are aggregated to determine the overall measure score for the population.

**Examples:** 

 *  the median time from arrival in the Emergency Room to departure
 *  the median time from decision to admit to a hospital to the actual admission for Emergency Room patients


Code: MSRPOPL
Display: measure population
Definition:
Criteria for specifying the measure population as a narrative description (e.g., all patients seen in the Emergency Department during the measurement period). This is used only in continuous variable eMeasures.


Code: MSRPOPLEX
Display: measure population exclusions
Definition:
Criteria for specifying subjects who should be removed from the eMeasure's Initial Population and Measure Population. Measure Population Exclusions are used in Continuous Variable measures to help narrow the Measure Population before determining the value(s) of the continuous variable(s).


Code: NUMER
Display: numerator
Definition:
Criteria for specifying the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator for proportion measures, or related to (but not directly derived from) the denominator for ratio measures (e.g., a numerator listing the number of central line blood stream infections and a denominator indicating the days per thousand of central line usage in a specific time period).


Code: NUMEX
Display: numerator exclusions
Definition:
Criteria for specifying instances that should not be included in the numerator data. (e.g., if the number of central line blood stream infections per 1000 catheter days were to exclude infections with a specific bacterium, that bacterium would be listed as a numerator exclusion). Numerator Exclusions are used only in ratio eMeasures.


Code: CIRCLE
Display: circle
Definition:
A circle defined by two (column,row) pairs. The first point is the center of the circle and the second point is a point on the perimeter of the circle.


Code: ELLIPSE
Display: ellipse
Definition:
An ellipse defined by four (column,row) pairs, the first two points specifying the endpoints of the major axis and the second two points specifying the endpoints of the minor axis.


Code: POINT
Display: point
Definition:
A single point denoted by a single (column,row) pair, or multiple points each denoted by a (column,row) pair.


Code: POLY
Display: polyline
Definition:
A series of connected line segments with ordered vertices denoted by (column,row) pairs; if the first and last vertices are the same, it is a closed polygon.


Code: B
Display: business information sensitivity
Definition:
Policy for handling trade secrets such as financial information or intellectual property, which will be afforded heightened confidentiality. Description: Since the service class can represent knowledge structures that may be considered a trade or business secret, there is sometimes (though rarely) the need to flag those items as of business level confidentiality.

*Usage Notes:* No patient related information may ever be of this confidentiality level. If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: EMPL
Display: employer information sensitivity
Definition:
Policy for handling information related to an employer which is deemed classified to protect an employee who is the information subject, and which will be afforded heightened confidentiality. Description: Policies may govern sensitivity of information related to an employer, such as law enforcement or national security, the identity of which could impact the privacy, well-being, or safety of an information subject who is an employee.

*Usage Notes:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: LOCIS
Display: location information sensitivity
Definition:
Policy for handling information related to the location of the information subject, which will be afforded heightened confidentiality. Description: Policies may govern sensitivity of information related to the location of the information subject, the disclosure of which could impact the privacy, well-being, or safety of that subject.

*Usage Notes:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: SSP
Display: sensitive service provider information sensitivity
Definition:
Policy for handling information related to a provider of sensitive services, which will be afforded heightened confidentiality. Description: Policies may govern sensitivity of information related to providers who deliver sensitive healthcare services in order to protect the privacy, well-being, and safety of the provider and of patients receiving sensitive services.

*Usage Notes:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law rather than or in addition to this more generic code.


Code: FULFIL
Display: fulfillment alert
Definition:
**Definition:**The therapy being performed is in some way out of alignment with the requested therapy.


Code: HELD
Display: held/suspended alert
Definition:
**Definition:**There should be no actions taken in fulfillment of a request that has been held or suspended.


Code: TOOLATE
Display: Refill Too Late Alert
Definition:
The patient is receiving a subsequent fill significantly later than would be expected based on the amount previously supplied and the therapy dosage instructions


Code: TOOSOON
Display: Refill Too Soon Alert
Definition:
The patient is receiving a subsequent fill significantly earlier than would be expected based on the amount previously supplied and the therapy dosage instructions


Code: ENDLATE
Display: End Too Late Alert
Definition:
Proposed therapy may be inappropriate or ineffective because the end of administration is too close to another planned therapy


Code: STRTLATE
Display: Start Too Late Alert
Definition:
Proposed therapy may be inappropriate or ineffective because the start of administration is too late after the onset of the condition


Code: 22
Display: appropriate indication or diagnosis
Definition:
**Description:** The patient has the appropriate indication or diagnosis for the action to be taken.


Code: 20
Display: additional quantity on separate dispense
Definition:
**Description:** Supply is different than expected as an additional quantity has been supplied in a separate dispense.


Code: ANF
Display: adjudicated with adjustments and no financial impact
Definition:
The invoice element has been accepted for payment but one or more adjustment(s) have been made to one or more invoice element line items (component charges) without changing the amount.

Invoice element can be reversed (nullified).

Recommend that the invoice element is saved for DUR (Drug Utilization Reporting).


Code: TRSTACCRD
Display: trust accreditation
Definition:
Type of security metadata about the formal declaration by an authority or neutral third party that validates the technical, security, trust, and business practice conformance of Trust Agents to facilitate security, interoperability, and trust among participants within a security domain or trust framework.


Code: TRSTAGRE
Display: trust agreement
Definition:
Type of security metadata about privacy and security requirements with which a security domain must comply. \[ISO IEC 10181-1\]


Code: TRSTASSUR
Display: trust assurance
Definition:
Type of security metadata about the digital quality or reliability of a trust assertion, activity, capability, information exchange, mechanism, process, or protocol.


Code: TRSTCERT
Display: trust certificate
Definition:
Type of security metadata about a set of security-relevant data issued by a security authority or trusted third party, together with security information which is used to provide the integrity and data origin authentication services for an IT resource (data, information object, service, or system capability). \[Based on ISO IEC 10181-1\]


Code: TRSTFWK
Display: trust framework
Definition:
Type of security metadata about a complete set of contracts, regulations, or commitments that enable participating actors to rely on certain assertions by other actors to fulfill their information security requirements. \[Kantara Initiative\]


Code: TRSTMEC
Display: trust mechanism
Definition:
Type of security metadata about a security architecture system component that supports enforcement of security policies.


Code: ACCESSCONSCHEME
Display: access control scheme
Definition:
An access control policy specific to the type of access control scheme, which is used to enforce one or more authorization policies.

*Usage Note:* Access control schemes are the type of access control policy, which is comprised of access control policy rules concerning the provision of the access control service.

There are two categories of access control policies, rule-based and identity-based, which are identified in CCITT Rec. X.800 aka ISO 7498-2. Rule-based access control policies are intended to apply to all access requests by any initiator on any target in a security domain. Identity-based access control policies are based on rules specific to an individual initiator, a group of initiators, entities acting on behalf of initiators, or originators acting in a specific role. Context can modify rule-based or identity-based access control policies. Context rules may define the entire policy in effect. Real systems will usually employ a combination of these policy types; if a rule-based policy is used, then an identity-based policy is usually in effect also.

An access control scheme may be based on access control lists, capabilities, labels, and context or a combination of these. An access control scheme is a component of an access control mechanism or "service") along with the supporting mechanisms required by that scheme to provide access control decision information (ADI) supplied by the scheme to the access decision facility (ADF also known as a PDP). (Based on ISO/IEC 10181-3:1996)

**Examples:** 

 *  Attribute Based Access Control (ABAC)
 *  Discretionary Access Control (DAC)
 *  History Based Access Control (HBAC)
 *  Identity Based Access Control (IBAC)
 *  Mandatory Access Control (MAC)
 *  Organization Based Access Control (OrBAC)
 *  Relationship Based Access Control (RelBac)
 *  Responsibility Based Access Control (RespBAC)
 *  Risk Adaptable Access Control (RAdAC)

>


Code: COL
Display: collision coverage policy
Definition:
**Definition:** An automobile insurance policy under which the insurance company will cover the cost of damages to an automobile owned by the named insured that are caused by accident or intentionally by another party.


Code: UNINSMOT
Display: uninsured motorist policy
Definition:
**Definition:** An automobile insurance policy under which the insurance company will indemnify a loss for which another motorist is liable if that motorist is unable to pay because he or she is uninsured. Coverage under the policy applies to bodily injury damages only. Injuries to the covered party caused by a hit-and-run driver are also covered.


Code: COGN
Display: cognitive disability information sensitivity
Definition:
Policy for handling information related to cognitive disability disorders and conditions caused by these disorders, which are afforded heightened confidentiality.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law in addition to this more generic code.

Examples may include dementia, traumatic brain injury, attention deficit, hearing and visual disability such as dyslexia and other disorders and related conditions which impair learning and self-sufficiency. However, the cognitive disabilities to which this term may apply versus other behavioral health categories varies by jurisdiction and organizational policy in part due to overlap with other behavioral health conditions. Implementers should constrain to those diagnoses applicable in the domain in which this code is used.


Code: DVD
Display: developmental disability information sensitivity
Definition:
Policy for handling information related to developmental disability disorders and conditions caused by these disorders, which is afforded heightened confidentiality.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law in addition to this more generic code.

A diverse group of chronic conditions that are due to mental or physical impairments impacting activities of daily living, self-care, language acuity, learning, mobility, independent living and economic self-sufficiency. Examples may include Down syndrome and Autism spectrum. However, the developmental disabilities to which this term applies versus other behavioral health categories varies by jurisdiction and organizational policy in part due to overlap with other behavioral health conditions. Implementers should constrain to those diagnoses applicable in the domain in which this code is used.


Code: EMOTDIS
Display: emotional disturbance information sensitivity
Definition:
Policy for handling information related to emotional disturbance disorders and conditions caused by these disorders, which is afforded heightened confidentiality.

*Usage Note:* If there is a jurisdictional mandate, then use the applicable ActPrivacyLaw code system, and specify the law in addition to this more generic code.

Typical used to characterize behavioral and mental health issues of adolescents where the disorder may be temporarily diagnosed in order to avoid the potential and unnecessary stigmatizing diagnoses of disorder long term.


Code: CODE_DEPREC
Display: code has been deprecated
Definition:
**Description:**The specified code has been deprecated and should no longer be used. Select another code from the code system.


Code: ABUSE
Display: commonly abused/misused alert
Definition:
**Description:**The proposed therapy is frequently misused or abused and therefore should be used with caution and/or monitoring.


Code: PLYPHRM
Display: Poly-supplier Alert
Definition:
This patient was recently supplied a similar or identical therapy from a different pharmacy or supplier.


Code: ACOCOMPT
Display: accountable care organization compartment
Definition:
A group of health care entities, which may include health care providers, care givers, hospitals, facilities, health plans, and other health care constituents who coordinate care for reimbursement based on quality metrics for improving outcomes and lowering costs, and may be authorized to access the consumer's health information because of membership in that group.

Security Compartment Labels assigned to a consumer's information use in accountable care workflows should be met or exceeded by the Security Compartment attribute claimed by a participant in a an accountable care workflow who is requesting access to that information


Code: CDSSCOMPT
Display: CDS system compartment
Definition:
This compartment code may be used as a field value in an initiator's clearance to indicate permission for its Clinical Decision Support system (CDSS) to access and use an IT Resource with a security label having the same compartment value in the security category label field.

This code permits a CDS system to algorithmically process information with this compartment tag for the purpose of alerting an unauthorized end user that masked information is needed to address an emergency or a patient safety issue, such as a contraindicated medication. The alert would advise the end user to "break the glass", to access the masked information in an accountable manner, or to ask the patient about possibly masked information.

For example, releasing a list of sensitive medications with this compartment tag means that while the CDS system is permitted to use this list in its contraindication analysis, this sensitive information should not be shared directly with unauthorized end-users or end-user-facing Apps. Based on the results of the CDS system analysis (e.g., warnings about prescriptions) the end-user (e.g., a clinician) may still have the ability to access to the sensitive information by invoking "break-the-glass protocol".

*Usage Note:* A security label with the CDS system compartment may be used in conjunction with other security labels, e.g., a label authorizing an end user with adequate clearance to access the same CDS system compartment tagged information. For example, a patient may restrict sharing sensitive information with most care team members except in an emergency or to prevent an adverse event, and may consent to sharing with their sensitive service care team providers, e.g., for mental health or substance abuse.


Code: CTCOMPT
Display: care team compartment
Definition:
Care coordination across participants in a care plan requires sharing of a healthcare consumer's information specific to that workflow. A care team member should only have access to that information while participating in that workflow or for other authorized uses.

Security Compartment Labels assigned to a consumer's information use in care coordination workflows should be met or exceeded by the Security Compartment attribute claimed by a participant in a care team member workflow who is requesting access to that information


Code: FMCOMPT
Display: financial management compartment
Definition:
Financial management department members who have access to healthcare consumer information as part of a patient account, billing and claims workflows.

Security Compartment Labels assigned to consumer information used in these workflows should be met or exceeded by the Security Compartment attribute claimed by a participant in a financial management workflow who is requesting access to that information.


Code: HRCOMPT
Display: human resource compartment
Definition:
A security category label field value, which indicates that access and use of an IT resource is restricted to members of human resources department or workflow.


Code: LRCOMPT
Display: legitimate relationship compartment
Definition:
Providers and care givers who have an established relationship per criteria determined by policy are considered to have an established care provision relations with a healthcare consumer, and may be authorized to access the consumer's health information because of that relationship. Providers and care givers should only have access to that information while participating in legitimate relationship workflows or for other authorized uses.

Security Compartment Labels assigned to a consumer's information use in legitimate relationship workflows should be met or exceeded by the Security Compartment attribute claimed by a participant in a legitimate relationship workflow who is requesting access to that information.


Code: PACOMPT
Display: patient administration compartment
Definition:
Patient administration members who have access to healthcare consumer information as part of a patient administration workflows.

Security Compartment Labels assigned to consumer information used in these workflows should be met or exceeded by the Security Compartment attribute claimed by a participant in a patient administration workflow who is requesting access to that information.


Code: RESCOMPT
Display: research project compartment
Definition:
A security category label field value, which indicates that access and use of an IT resource is restricted to members of a research project.


Code: RMGTCOMPT
Display: records management compartment
Definition:
A security category label field value, which indicates that access and use of an IT resource is restricted to members of records management department or workflow.


Code: CONTROLLED
Display: CONTROLLED
Definition:
A displayed mark, required to be rendered as "CONTROLLED", indicating that the electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Mandatory control marking, which must be displayed on the top portion of each rendered or printed page containing controlled information. Should be displayed at the bottom of each rendered or printed page containing controlled information. Must be displayed on each portion of controlled information at the portion level if portions are uncontrolled unclassified information. Based on CUI Marking Handbook https://www.archives.gov/files/cui/20161206-cui-marking-handbook-v1-1.pdf.


Code: CUI
Display: CUI
Definition:
A displayed mark, required to be rendered as "CUI", indicating that the electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Mandatory control marking, which must be displayed on the top portion of each rendered or printed page containing controlled information. Should be displayed at the bottom of each rendered or printed page containing controlled information. Must be displayed on each portion of controlled information at the portion level if portions are uncontrolled unclassified information. Based on CUI Marking Handbook https://www.archives.gov/files/cui/20161206-cui-marking-handbook-v1-1.pdf.


Code: CUIHLTH
Display: CUI//HLTH
Definition:
A displayed mark, required to be rendered as "CUI//HLTH", indicating that the electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of healthcare regulation governing CUI Basic marking include HIPAA Unique Identifier provisions 42 USC 1320d-2 note(b) https://www.govinfo.gov/content/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXI-partC-sec1320d-2.pdf; Title 38 Section 7332 https://www.govinfo.gov/content/pkg/USCODE-2016-title38/pdf/USCODE-2016-title38-partV-chap73-subchapIII-sec7332.pdf; and several sections of 42 CFR Part 2.related to consent and confidentiality, e.g., https://www.govinfo.gov/content/pkg/CFR-2017-title42-vol1/pdf/CFR-2017-title42-vol1-sec2-12.pdf


Code: CUIHLTHP
Display: (CUI//HLTH)
Definition:
A displayed mark, required to be rendered as "(CUI//HLTH)", indicating that a portion of an electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of healthcare regulation governing CUI Basic marking include HIPAA Unique Identifier provisions 42 USC 1320d-2 note(b) https://www.govinfo.gov/content/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXI-partC-sec1320d-2.pdf; Title 38 Section 7332 https://www.govinfo.gov/content/pkg/USCODE-2016-title38/pdf/USCODE-2016-title38-partV-chap73-subchapIII-sec7332.pdf; and several sections of 42 CFR Part 2.related to consent and confidentiality, e.g., https://www.govinfo.gov/content/pkg/CFR-2017-title42-vol1/pdf/CFR-2017-title42-vol1-sec2-12.pdf


Code: CUIP
Display: (CUI)
Definition:
A displayed mark, required to be rendered as "(CUI)", indicating that a portion of an electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of healthcare regulation governing CUI Basic marking include HIPAA Unique Identifier provisions 42 USC 1320d-2 note(b) https://www.govinfo.gov/content/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXI-partC-sec1320d-2.pdf; Title 38 Section 7332 https://www.govinfo.gov/content/pkg/USCODE-2016-title38/pdf/USCODE-2016-title38-partV-chap73-subchapIII-sec7332.pdf; and several sections of 42 CFR Part 2.related to consent and confidentiality, e.g., https://www.govinfo.gov/content/pkg/CFR-2017-title42-vol1/pdf/CFR-2017-title42-vol1-sec2-12.pdf


Code: CUIPRVCY
Display: CUI//PRVCY
Definition:
A displayed mark, required to be rendered as "CUI//PRVCY", indicating that the electronic or hardcopy controlled unclassified basic privacy information is private and must be protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of privacy regulation governing CUI Basic marking include 20 CFR 401.100 related to SSA disclosure of personal, program, and non-program information. https://www.govinfo.gov/content/pkg/CFR-2017-title20-vol2/pdf/CFR-2017-title20-vol2-sec401-100.pdf.


Code: CUIPRVCYP
Display: (CUI//PRVCY)
Definition:
A displayed mark, required to be rendered as "(CUI//PRVCY)", indicating that a portion of an electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of privacy regulation governing CUI Basic marking include 20 CFR 401.100 related to SSA disclosure of personal, program, and non-program information. https://www.govinfo.gov/content/pkg/CFR-2017-title20-vol2/pdf/CFR-2017-title20-vol2-sec401-100.pdf.


Code: CUISP-HLTH
Display: CUI//SP-HLTH
Definition:
A displayed mark, required to be rendered as "CUI//SP-HLTH", indicating that the electronic or hardcopy information is protected at the level of the subset of CUI in which the authorizing law, regulation, or Government-wide policy contains specific handling controls that it requires or permits agencies to use that differ from those for CUI Basic. The CUI Registry indicates which laws, regulations, and Government-wide policies include such specific requirements. CUI Specified controls may be more stringent than, or may simply differ from, those required by CUI Basic; the distinction is that the underlying authority spells out the controls for CUI Specified information and does not for CUI Basic information. CUI Basic controls apply to those aspects of CUI Specified where the authorizing laws, regulations, and Government-wide policies do not provide specific guidance. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of healthcare regulation governing CUI Specified marking include HIPAA Transaction and Code Sets and references the Congressional requirement that HHS promulgate Privacy, and Security rules https://www.govinfo.gov/content/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXI-partC-sec1320d-2.pdf.


Code: CUISP-HLTHP
Display: (CUI//SP-HLTH)
Definition:
A displayed mark, required to be rendered as "(CUI//SP-HLTH)", indicating that a portion of an electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of healthcare regulation governing CUI Specified marking include HIPAA Transaction and Code Sets and references the Congressional requirement that HHS promulgate Privacy, and Security rules https://www.govinfo.gov/content/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXI-partC-sec1320d-2.pdf


Code: CUISP-PRVCY
Display: CUI//SP-PRVCY
Definition:
A displayed mark, required to be rendered as "CUI//SP-PRVCY", indicating that the electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of privacy regulation governing CUI Specified marking is OMB M-17-12ï‡? This Memorandum sets forth the policy for Federal agencies to prepare for and respond to a breach of personally identifiable information (PII). It includes a framework for assessing and mitigating the risk of harm to individuals potentially affected by a breach, as well as guidance on whether and how to provide notification and services to those individuals. https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/memoranda/2017/m-17-12\_0.pdf.


Code: CUISP-PRVCYP
Display: (CUI//SP-PRVCY)
Definition:
A displayed mark, required to be rendered as "(CUI//SP-PRVCY)", indicating that a portion of an electronic or hardcopy information is protected at the level of the subset of CUI for which the authorizing law, regulation, or Government-wide policy does not set out specific handling or dissemination controls. Agencies handle CUI Basic according to the uniform set of controls set forth in this part and the CUI Registry. CUI Basic differs from CUI Specified (see definition for CUI Specified), and CUI Basic controls apply whenever CUI Specified ones do not cover the involved CUI. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.

*Usage Note:* Examples of privacy regulation governing CUI Specified marking is OMB M-17-12ï‡? This Memorandum sets forth the policy for Federal agencies to prepare for and respond to a breach of personally identifiable information (PII). It includes a framework for assessing and mitigating the risk of harm to individuals potentially affected by a breach, as well as guidance on whether and how to provide notification and services to those individuals. https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/memoranda/2017/m-17-12\_0.pdf.


Code: UUI
Display: (U)
Definition:
A displayed mark, required to be rendered as "(U)", indicating that a portion of an electronic or hardcopy information is neither Executive Order 13556 nor classified information authorities cover as protected. Although this information is not controlled or classified, agencies must still handle it in accordance with Federal Information Security Modernization Act (FISMA) requirements. From CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html

*Usage Note:* Regulatory Source: 32 CFR §  2002.20 Marking. Federal Register Page 63344 63344 (ii) Authorized holders permitted to designate CUI must portion mark both CUI and uncontrolled unclassified portions.

CUI Marking Handbook https://www.archives.gov/files/cui/20161206-cui-marking-handbook-v1-1.pdf

CUI Portion Marking: Portion marking of CUI is optional in a fully unclassified document, but is permitted and encouraged to facilitate information sharing and proper handling of the information. Agency heads may approve the required use of CUI Portion marking on all CUI generated within their agency. As such, users should consult their agency CUI policy when creating CUI documents. When CUI Portion Markings are used and a portion does not contain CUI a "U" is placed in parentheses to indicate that the portion contains Uncontrolled Unclassified Information. (Page 14)

CUI Portion Markings are placed at the beginning of the portion to which they apply and must be used throughout the entire document. They are presented in all capital letters and separated as indicated in this handbook and the CUI Registry. The presence of EVEN ONE item of CUI in a document requires CUI marking of that document. Because of this, CUI Portion Markings can be of great assistance in determining if a document contains CUI and therefore must be marked as such. Remember: When portion markings are used and any portion does not contain CUI, a "(U)" is placed in front of that portion to indicate that it contains Uncontrolled - or non-CUI - Unclassified Information. (Page 15)


Code: CPLYCC
Display: comply with confidentiality code
Definition:
Custodian security system must retrieve, evaluate, and comply with the information handling directions of the Confidentiality Code associated with an information target.

*Usage Note:* CPLYCC may be used as a security label code to inform senders and receivers of information tagged with a Confidentiality Code to comply with applicable level of protection required by the assigned confidentiality code.


Code: CPLYCD
Display: comply with consent directive
Definition:
Custodian security system must retrieve, evaluate, and comply with applicable information subject consent directives.

*Usage Note:* CPLYCD may be used as a security label code to inform senders and receivers of information tagged with an ActCode\_ActPolicyType\_ActConsent code or an ActCode\_ActPolicyType\_ActPrivacyPolicy\_ActConsentDirective code to comply with applicable consent directives.


Code: CPLYCUI
Display: comply with controlled unclassified information policy
Definition:
Custodian security system must retrieve, evaluate, and comply with applicable Controlled Unclassified Information (CUI) policies associated with the target information.

*Usage Note:* In the US, CPLYCUI may be used as a security label code to inform recipients of information designated by a US Federal Agency as Controlled Unclassified Information (CUI) to comply with the applicable laws, regulations, executive orders, and other guidances, such as included in DURSAs, to persist, mark, and enforce required CUI controls

Background:

In accordance with US 32 CFR Part 2002 and US Executive Order 13556 Controlled Unclassified Information, US Federal Agencies and their contractors are charged with classifying and marking certain information they create as Controlled Unclassified Information (CUI).

The following definitions, which are provided for context, are based on terms defined by the CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html

 *  CUI is defined as "information in any form that the Government creates or possesses, or that an entity creates or possesses for or on behalf of the Government, that a law, regulation, or Government-wide policy requires or permits an agency to handle using safeguarding or dissemination controls."
 *  Designating CUI occurs when an authorized holder, consistent with 32 CFR Part 2002 and the CUI Registry, determines that a specific item of information falls into a CUI category or subcategory.
 *  The designating agency is the executive branch agency that designates or approves the designation of a specific item of information as CUI.
 *  The authorized holder who designates the CUI must make recipients aware of the information's CUI status when disseminating that information.
 *  • Disseminating occurs when authorized holders provide access, transmit, or transfer CUI to other authorized holders through any means, whether internal or external to the agency.

Once designated as CUI, US Federal Agencies and their contractors must assign CUI marks as prescribed by the National Archives and Records Administration (NARA) CUI Registry, and display marks as prescribed by the CUI Marking Handbook.

CUI markings must be displayed on hard copy, on containers, electronic media, and to end users for IT systems.

When HL7 content is designated as CUI, these computable markings can be interoperably conveyed using HL7 security label CUI tags, and may be included in HL7 text and narrative elements as human readable markings.

**Impact of CUI markings:**

CUI Custodians must enforce CUI security controls per applicable CUI policies. Federal agencies and their contractors must adhere to FISMA and NIST SP 800-53 security controls. Custodians, who are not Federal agencies or agency contractors, and are receivers of CUI, must adhere to NIST SP 800-171 security controls and those dictated by the Authorities indicated by the assigned CUI markings.

For most participants in US healthcare information exchange, including Federal Agencies and their contractors, additional controls are required by HIPAA Security standards for health information US 42 USC 1320d-2(d)(2) https://www.govinfo.gov/content/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXI-partC-sec1320d-2.pdf

Federal Agencies and their contractors may be the CUI classifier of original CUI content; or a CUI derivative classifier, which reclassifies CUI content that has been aggregated with other CUI or Unclassified Uncontrolled Information (U) or dissembled from a larger CUI content; or declassifiers, depending on the designating agency's policies.

Applicable CUI policies include the following and any future applicable updates to policies or laws related to CUI:

 *  Executive Order 13556 https://www.federalregister.gov/articles/2010/11/09/2010-28360/controlled-unclassified-information
 *  US 32 CFR Part 2002 https://www.govinfo.gov/content/pkg/CFR-2017-title32-vol6/pdf/CFR-2017-title32-vol6-part2002.pdf
 *  NIST SP 800-171 https://nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-171r1.pdf
 *  NIST SP 800-171A https://doi.org/10.6028/NIST.SP.800-171A
 *  CUI Marking Handbook https://www.archives.gov/files/cui/20161206-cui-marking-handbook-v1-1.pdf
 *  CUI Registry - Health Information Category https://www.archives.gov/cui/registry/category-detail/health-info
 *  CUI Registry: Limited Dissemination Controls https://www.archives.gov/cui/registry/limited-dissemination
 *  CUI Policy and Guidance https://www.archives.gov/cui/registry/policy-guidance


Code: CPLYJPP
Display: comply with jurisdictional privacy policy
Definition:
Custodian security system must retrieve, evaluate, and comply with applicable jurisdictional privacy policies associated with the target information.

*Usage Note:* CPLYJPP may be used as a security label code to inform senders and receivers of information tagged with an ActCode\_ActPolicyType\_ActPrivacyPolicy\_ActPrivacyLaw code or an ActCode\_ActPolicyType\_ActInformationPolicy.JurisIP code to comply with applicable jurisdictional privacy policy.


Code: CPLYJSP
Display: comply with jurisdictional security policy
Definition:
Custodian security system must retrieve, evaluate, and comply with applicable jurisdictional security policies associated with the target information.

*Usage Note:* CPLYJSP may be used as a security label code to inform senders and receivers of information tagged with an ActCode\_ActPolicyType.SecurityPolicy code to comply with applicable jurisdictional security policy.


Code: CPLYOPP
Display: comply with organizational privacy policy
Definition:
Custodian security system must retrieve, evaluate, and comply with applicable organizational privacy policies associated with the target information.

*Usage Note:* CPLYOPP may be used as a security label code to inform senders and receivers of information tagged with an ActCode\_ActPolicyType\_ActInformationPolicy.OrgIP code to comply with applicable organizational privacy policy.


Code: CPLYOSP
Display: comply with organizational security policy
Definition:
Custodian security system must retrieve, evaluate, and comply with the organizational security policies associated with the target information.

*Usage Note:* CPLYOSP may be used as a security label code to inform senders and receivers of information tagged with an ActCode\_ActPolicyType.SecurityPolicy code to comply with applicable organizational security policy.


Code: DM
Display: diabetes mellitus diet
Definition:
A diet that uses carbohydrates sparingly. Typically with a restriction in daily energy content (e.g. 1600-2000 kcal).


Code: FAST
Display: fasting
Definition:
No enteral intake of foot or liquids whatsoever, no smoking. Typically 6 to 8 hours before anesthesia.


Code: FORMULA
Display: formula diet
Definition:
A diet consisting of a formula feeding, either for an infant or an adult, to provide nutrition either orally or through the gastrointestinal tract via tube, catheter or stoma.


Code: LQ
Display: liquid
Definition:
A strictly liquid diet, that can be fully absorbed in the intestine, and therefore may not contain fiber. Used before enteral surgeries.


Code: N
Display: normal diet
Definition:
A normal diet, i.e. no special preparations or restrictions for medical reasons. This is notwithstanding any preferences the patient might have regarding special foods, such as vegetarian, kosher, etc.


Code: SCH
Display: schonkost (GE)
Definition:
A diet that avoids ingredients that might cause digestion problems, e.g., avoid excessive fat, avoid too much fiber (cabbage, peas, beans).


Code: T
Display: tea only
Definition:
This is not really a diet, since it contains little nutritional value, but is essentially just water. Used before coloscopy examinations.


Code: CANPRG
Display: women's cancer detection program
Definition:
**Definition:** A program that provides low-income, uninsured, and underserved women access to timely, high-quality screening and diagnostic services, to detect breast and cervical cancer at the earliest stages.

**Example:** To improve women's access to screening for breast and cervical cancers, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990, which guided CDC in creating the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides access to critical breast and cervical cancer screening services for underserved women in the United States. An estimated 7 to 10% of U.S. women of screening age are eligible to receive NBCCEDP services. Federal guidelines establish an eligibility baseline to direct services to uninsured and underinsured women at or below 250% of federal poverty level; ages 18 to 64 for cervical screening; ages 40 to 64 for breast screening.


Code: ENDRENAL
Display: end renal program
Definition:
**Definition:** A public or government program that administers publicly funded coverage of kidney dialysis and kidney transplant services.

Example: In the U.S., the Medicare End-stage Renal Disease program (ESRD), the National Kidney Foundation (NKF) American Kidney Fund (AKF) The Organ Transplant Fund.


Code: HIVAIDS
Display: HIV-AIDS program
Definition:
**Definition:** Government administered and funded HIV-AIDS program for beneficiaries meeting financial and health status criteria. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors.

**Example:** In the U.S., the Ryan White program, which is administered by the Health Resources and Services Administration.


Code: MDOSE
Display: maximum dosage reached
Definition:
**Description:**The maximum quantity of this drug allowed to be administered within a particular time-range (month, year, lifetime) has been reached or exceeded.


Code: DOSEDURHIND
Display: Dose-Duration High for Indication Alert
Definition:
Proposed length of therapy is longer than standard practice for the identified indication or diagnosis


Code: DOSEDURLIND
Display: Dose-Duration Low for Indication Alert
Definition:
Proposed length of therapy is shorter than standard practice for the identified indication or diagnosis


Code: DOSEIVLIND
Display: Dose-Interval for Indication Alert
Definition:
Proposed dosage interval/timing differs from standard practice for the identified indication or diagnosis


Code: DUPTHPCLS
Display: duplicate therapeutic alass alert
Definition:
**Description:**The proposed therapy appears to have the same intended therapeutic benefit as an existing therapy, though the specific mechanisms of action vary.


Code: DUPTHPGEN
Display: duplicate generic alert
Definition:
**Description:**The proposed therapy appears to have the same intended therapeutic benefit as an existing therapy and uses the same mechanisms of action as the existing therapy.


Code: SO
Display: Script Owing
Definition:
An emergency supply where the expectation is that a formal order authorizing the supply will be provided at a later date.


Code: 21
Display: authorization confirmed
Definition:
**Description:** Indicates that the permissions have been externally verified and the request should be processed.


Code: ENCRYPTR
Display: encrypt at rest
Definition:
Custodian system must render information unreadable and unusable by algorithmically transforming plaintext into ciphertext when "at rest" or in storage.


Code: ENCRYPTT
Display: encrypt in transit
Definition:
Custodian system must render information unreadable and unusable by algorithmically transforming plaintext into ciphertext while "in transit" or being transported by any means.


Code: ENCRYPTU
Display: encrypt in use
Definition:
Custodian system must render information unreadable and unusable by algorithmically transforming plaintext into ciphertext while in use such that operations permitted on the target information are limited by the license granted to the end user.


Code: FFC
Display: First Fill - Complete
Definition:
A first fill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets).


Code: FFP
Display: First Fill - Part Fill
Definition:
A first fill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.)


Code: FFPS
Display: first fill, part fill, partial strength
Definition:
A first fill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.) and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets)


Code: FFSS
Display: first fill, partial strength
Definition:
A first fill where the strength supplied is less than the ordered strength. (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).


Code: TF
Display: Trial Fill
Definition:
A fill where a small portion is provided to allow for determination of the therapy effectiveness and patient tolerance.


Code: FFCS
Display: first fill complete, partial strength
Definition:
A first fill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets) and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).


Code: TFS
Display: trial fill partial strength
Definition:
A fill where a small portion is provided to allow for determination of the therapy effectiveness and patient tolerance and also where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).


Code: NOTACTN
Display: no longer actionable
Definition:
**Definition:**The status of the request being fulfilled has changed such that it is no longer actionable. This may be because the request has expired, has already been completely fulfilled or has been otherwise stopped or disabled. (Not used for 'suspended' orders.)


Code: NOTEQUIV
Display: not equivalent alert
Definition:
**Definition:**The therapy being performed is not sufficiently equivalent to the therapy which was requested.


Code: TIMING
Display: event timing incorrect alert
Definition:
**Definition:**The therapy is being performed at a time which diverges from the time the therapy was requested


Code: INFAO
Display: access only
Definition:
**Definition:** Consent to access or "read" only, which entails that the information is not to be copied, screen printed, saved, emailed, stored, re-disclosed or altered in any way. This level ensures that data which is masked or to which access is restricted will not be.

**Example:** Opened and then emailed or screen printed for use outside of the consent directive purpose.


Code: INFASO
Display: access and save only
Definition:
**Definition:** Consent to access and save only, which entails that access to the saved copy will remain locked.


Code: INFCON
Display: after explicit consent
Definition:
Authorization to collect, access, use, or disclose specified patient health information as explicitly consented to by the subject of the information or the subject's representative.


Code: FIBRIN
Display: Fibrin
Definition:
The Fibrin Index of the specimen. In the case of only differentiating between Absent and Present, recommend using 0 and 1


Code: ICTERUS
Display: Icterus
Definition:
An observation that describes the icterus index of the specimen. It is recommended to use mMol/L of bilirubin


Code: LIPEMIA
Display: Lipemia
Definition:
An observation used to describe the Lipemia Index of the specimen. It is recommended to use the optical turbidity at 600 nm (in absorbance units).


Code: IPPOP
Display: initial patient population
Definition:
Criteria for specifying the patients to be evaluated by a specific quality measure, based on a shared common set of characteristics (within a specific measurement set to which a given measure belongs). Details often include information based upon specific age groups, diagnoses, diagnostic and procedure codes, and enrollment periods.


Code: JurisCUI
Display: jurisdictional controlled unclassified information policy
Definition:
Jurisdictional policy on collection, access, use, or disclosure of controlled unclassified information as defined by applicable jurisdictional law.


Code: LEN_LONG
Display: length is too long
Definition:
**Description:**The length of the data specified is greater than the maximum length defined for the element.


Code: LEN_SHORT
Display: length is too short
Definition:
**Description:**The length of the data specified is less than the minimum length defined for the element.


Code: ANNU
Display: annuity policy
Definition:
**Definition:** A policy that, after an initial premium or premiums, pays out a sum at pre-determined intervals.

For example, a policy holder may pay $10,000, and in return receive $150 each month until he dies; or $1,000 for each of 14 years or death benefits if he dies before the full term of the annuity has elapsed.


Code: TLIFE
Display: term life insurance policy
Definition:
**Definition:** Life insurance under which the benefit is payable only if the insured dies during a specified period. If an insured dies during that period, the beneficiary receives the death payments. If the insured survives, the policy ends and the beneficiary receives nothing.


Code: ULIFE
Display: universal life insurance policy
Definition:
**Definition:** Life insurance under which the benefit is payable upon the insuredaTMs death or diagnosis of a terminal illness. If an insured dies during that period, the beneficiary receives the death payments. If the insured survives, the policy ends and the beneficiary receives nothing


Code: RENT
Display: Rent
Definition:
Temporary supply of a product with financial compensation, without transfer of ownership for the product.


Code: HMO
Display: health maintenance organization policy
Definition:
**Definition:** A policy for a health plan that provides coverage for health care only through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Eligibility to enroll in an HMO is determined by where a covered party lives or works.


Code: PPO
Display: preferred provider organization policy
Definition:
**Definition:** A network-based, managed care plan that allows a covered party to choose any health care provider. However, if care is received from a "preferred" (participating in-network) provider, there are generally higher benefit coverage and lower deductibles.


Code: MDHHS-5515MMHC
Display:
Michigan Consent to Share Behavioral Health Information for Care Coordination Purposes-Michigan Mental Health Code

Definition:
The State of Michigan standard privacy consent form for sharing of health information specific to behavioral health governed by the Michigan Mental Health Code Act 258 of 1974, which require patient authorization for purposes other than treatment, payment, and coordination of care, in accordance with Public Act 129 of 2014.

*Usage Note:* For legislative background, current MDHHS-5515 consent directive form, and provider and patient FAQs see http://www.michigan.gov/mdhhs/0,5885,7-339-71550\_2941\_58005-343686--,00.html


Code: MDHHS-5515Part2
Display:
Michigan Consent to Share Behavioral Health Information for Care Coordination Purposes-US 42 CFR Part 2

Definition:
The State of Michigan standard privacy consent form for sharing of health information specific to substance use information governed under US 42 CFR Part 2 in accordance with Public Act 129 of 2014.

*Usage Note:* For legislative background, current MDHHS-5515 consent directive form, and provider and patient FAQs see http://www.michigan.gov/mdhhs/0,5885,7-339-71550\_2941\_58005-343686--,00.html


Code: NOTEQUIVGEN
Display: not generically equivalent alert
Definition:
**Definition:**The therapy being performed is not generically equivalent (having the identical biological action) to the therapy which was requested.


Code: NOTEQUIVTHER
Display: not therapeutically equivalent alert
Definition:
**Definition:**The therapy being performed is not therapeutically equivalent (having the same overall patient effect) to the therapy which was requested.


Code: ANONY
Display: anonymize
Definition:
Custodian system must remove any information that could result in identifying the information subject.


Code: AOD
Display: accounting of disclosure
Definition:
Custodian system must make available to an information subject upon request an accounting of certain disclosures of the individual's protected health information over a period of time. Policy may dictate that the accounting include information about the information disclosed, the date of disclosure, the identification of the receiver, the purpose of the disclosure, the time in which the disclosing entity must provide a response and the time period for which accountings of disclosure can be requested.


Code: AUDIT
Display: audit
Definition:
Custodian system must monitor systems to ensure that all users are authorized to operate on information objects.


Code: AUDTR
Display: audit trail
Definition:
Custodian system must monitor and maintain retrievable log for each user and operation on information.


Code: CPLYPOL
Display: comply with policy
Definition:
Custodian security system must retrieve, evaluate, and comply with applicable policies associated with the target information.

*Usage Note:* CPLYPOL may be used as a security label code to inform senders and receivers of the tagged information to comply with applicable policy without specifying the specific policy type(s).


Code: DECLASSIFYLABEL
Display: declassify security label
Definition:
Custodian security system must declassify information assigned security labels by instantiating a new version of the classified information so as to break the binding of the classifying security label when assigning a new security label that marks the information as unclassified in accordance with applicable jurisdictional privacy policies associated with the target information. The system must retain an immutable record of the previous assignment and binding.


Code: DEID
Display: deidentify
Definition:
Custodian system must strip information of data that would allow the identification of the source of the information or the information subject.


Code: DOWNGRDLABEL
Display: downgrade security label
Definition:
Custodian security system must downgrade information assigned security labels by instantiating a new version of the classified information so as to break the binding of the classifying security label when assigning a new security label that marks the information as classified at a less protected level in accordance with applicable jurisdictional privacy policies associated with the target information. The system must retain an immutable record of the previous assignment and binding.


Code: DRIVLABEL
Display: derive security label
Definition:
Custodian security system must assign and bind security labels derived from compilations of information by aggregation or disaggregation in order to classify information compiled in the information systems under its control for collection, access, use and disclosure in accordance with applicable jurisdictional privacy policies associated with the target information. The system must retain an immutable record of the previous assignment and binding.


Code: ENCRYPT
Display: encrypt
Definition:
Custodian system must render information unreadable by algorithmically transforming plaintext into ciphertext.

*Usage Notes:* A mathematical transposition of a file or data stream so that it cannot be deciphered at the receiving end without the proper key. Encryption is a security feature that assures that only the parties who are supposed to be participating in a videoconference or data transfer are able to do so. It can include a password, public and private keys, or a complex combination of all. (Per Infoway.)


Code: LABEL
Display: assign security label
Definition:
Custodian security system must assign and bind security labels in order to classify information created in the information systems under its control for collection, access, use and disclosure in accordance with applicable jurisdictional privacy policies associated with the target information. The system must retain an immutable record of the assignment and binding.

*Usage Note:* In security systems, security policy label assignments do not change, they may supersede prior assignments, and such reassignments are always tracked for auditing and other purposes.


Code: MASK
Display: mask
Definition:
Custodian system must render information unreadable and unusable by algorithmically transforming plaintext into ciphertext. User may be provided a key to decrypt per license or "shared secret".


Code: MINEC
Display: minimum necessary
Definition:
Custodian must limit access and disclosure to the minimum information required to support an authorized user's purpose of use.

*Usage Note:* Limiting the information available for access and disclosure to that an authorized user or receiver "needs to know" in order to perform permitted workflow or purpose of use.


Code: PERSISTLABEL
Display: persist security label
Definition:
Custodian security system must persist the binding of security labels to classify information received or imported by information systems under its control for collection, access, use and disclosure in accordance with applicable jurisdictional privacy policies associated with the target information. The system must retain an immutable record of the assignment and binding.


Code: PRIVMARK
Display: privacy mark
Definition:
Custodian must create and/or maintain human readable security label tags as required by policy.

Map: Aligns with ISO 22600-3 Section A.3.4.3 description of privacy mark: "If present, the privacy-mark is not used for access control. The content of the privacy-mark may be defined by the security policy in force (identified by the security-policy-identifier) which may define a list of values to be used. Alternately, the value may be determined by the originator of the security-label."


Code: PSEUD
Display: pseudonymize
Definition:
Custodian system must strip information of data that would allow the identification of the source of the information or the information subject. Custodian may retain a key to relink data necessary to reidentify the information subject.


Code: REDACT
Display: redact
Definition:
Custodian system must remove information, which is not authorized to be access, used, or disclosed from records made available to otherwise authorized users.


Code: UPGRDLABEL
Display: upgrade security label
Definition:
Custodian security system must declassify information assigned security labels by instantiating a new version of the classified information so as to break the binding of the classifying security label when assigning a new security label that marks the information as classified at a more protected level in accordance with applicable jurisdictional privacy policies associated with the target information. The system must retain an immutable record of the previous assignment and binding.


Code: PROCESSINLINELABEL
Display: process inline security label
Definition:
Custodian security system must take note that the data object contains inline security labels and process them.


Code: CREACT
Display: common reaction alert
Definition:
**Description:**Proposed therapy may be inappropriate or contraindicated because of a common but non-patient specific reaction to the product.

**Example:**There is no record of a specific sensitivity for the patient, but the presence of the sensitivity is common and therefore caution is warranted.


Code: OrgNSI
Display: organizational non-sensitive information policy
Definition:
Organizational policy on collection, access, use, or disclosure of information deemed non-sensitive by the organization or by applicable jurisdictional law.


Code: OrgUUI
Display: organizational uncontrolled unclassified information policy
Definition:
Organizational policy on collection, access, use, or disclosure of uncontrolled unclassified information as defined by the organization or governing jurisdiction.


Code: CDSREV
Display: clinical decision support intervention review
Definition:
A person reviews a recommendation/assessment provided automatically by a clinical decision support application for a given patient.


Code: PATPREFALT
Display: violates stated preferences, alternate available
Definition:
**Definition:**The proposed therapy goes against preferences or consent constraints recorded in the patient's record. An alternate therapy meeting those constraints is available.


Code: ControlledUnclassifiedInformation
Display: ControlledUnclassifiedInformation
Definition:
Information the US Government creates or possesses, or that an entity creates or possesses for or on behalf of the Government, that a law, regulation, or Government-wide policy requires or permits an agency to handle using safeguarding or dissemination controls. However, CUI does not include classified information (see definition above) or information a non-executive branch entity possesses and maintains in its own systems that did not come from, or was not created or possessed by or for, an executive branch agency or an entity acting for an agency. Law, regulation, or Government-wide policy may require or permit safeguarding or dissemination controls in three ways: Requiring or permitting agencies to control or protect the information but providing no specific controls, which makes the information CUI Basic; requiring or permitting agencies to control or protect the information and providing specific controls for doing so, which makes the information CUI Specified; or requiring or permitting agencies to control the information and specifying only some of those controls, which makes the information CUI Specified, but with CUI Basic controls where the authority does not specify. Based on CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html .

*Usage Note:* Mandatory control marking, which must be displayed on the top portion of each rendered or printed page containing controlled information. Should be displayed at the bottom of each rendered or printed page containing controlled information. Must be displayed on each portion of controlled information at the portion level if portions are uncontrolled unclassified information. Based on CUI Marking Handbook https://www.archives.gov/files/cui/20161206-cui-marking-handbook-v1-1.pdf. For definitions of key terms see CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html.


Code: SecurityLabelMark
Display: Security Label Mark
Definition:
An abstract code for displayed Security Label tags.

*Usage Note:* These marks may be based on any of the HL7 Security Labeling related codes from various code systems and values sets, which are organized according to the HL7 Privacy and Security Classification System into HL7 Security Observation Type Named Tag Sets and valued with codes associated with the HL7 Security Observation Value Tag Set Names.


Code: CUIMark
Display: CUI Mark
Definition:
An originator must mark, persist, display, and convey computable and renderable Controlled Unclassified Information (CUI) marks as required by policy. A recipient must consume, persist, display, and reconvey CUI marks on information received based on agreements with the originator..

**Examples:** 

 *  As CUI custodians, Federal Agencies and their contractors must mark, persist, display, and convey these marks.
 *  All CUI receivers must consume, persist, display, and reconvey CUI markings on information further disclosed

*Usage Note:* 

In accordance with US 32 CFR Part 2002 and US Executive Order 13556 Controlled Unclassified Information, US Federal Agencies and their contractors are charged with classifying and marking certain information they create as Controlled Unclassified Information (CUI).

The following definitions, which are provided for context, are based on terms defined by the CUI Glossary https://www.archives.gov/cui/registry/cui-glossary.html

 *  CUI is defined as "information in any form that the Government creates or possesses, or that an entity creates or possesses for or on behalf of the Government, that a law, regulation, or Government-wide policy requires or permits an agency to handle using safeguarding or dissemination controls"
 *  Designating CUI occurs when an authorized holder, consistent with US 32 CFR Part 2002 and the CUI Registry, determines that a specific item of information falls into a CUI category or subcategory.
 *  The designating agency is the executive branch agency that designates or approves the designation of a specific item of information as CUI.
 *  The authorized holder who designates the CUI must make recipients aware of the information's CUI status when disseminating that information.
 *  Disseminating occurs when authorized holders provide access, transmit, or transfer CUI to other authorized holders through any means, whether internal or external to the agency.

Once designated as CUI, US Federal Agencies and their contractors must assign CUI marks as prescribed by the National Archives and Records Administration (NARA) CUI Registry, and display marks as prescribed by the CUI Marking Handbook.

CUI markings must be displayed on hard copy, on containers, electronic media, and to end users for IT systems.

When HL7 content is designated as CUI, these computable markings can be interoperably conveyed using HL7 security label CUI tags, and may be included in HL7 text and narrative elements as human readable markings.

**Impact of CUI markings:**

CUI Custodians must enforce CUI security controls per applicable CUI policies. Federal agencies and their contractors must adhere to FISMA and NIST SP 800-53 security controls. Custodians, who are not Federal agencies or agency contractors, and are receivers of CUI, must adhere to NIST SP 800-171 security controls and those dictated by the Authorities indicated by the assigned CUI markings.

For most participants in US healthcare information exchange, including Federal Agencies and their contractors, additional controls are required by HIPAA Security standards for health information US 42 USC 1320d-2(d)(2) https://www.govinfo.gov/content/pkg/USCODE-2016-title42/pdf/USCODE-2016-title42-chap7-subchapXI-partC-sec1320d-2.pdf

Federal Agencies and their contractors may be the CUI classifier of original CUI content; or a CUI derivative classifier, which reclassifies CUI content that has been aggregated with other CUI or Unclassified Uncontrolled Information (U) or dissembled from a larger CUI content; or declassifiers, depending on the designating agency's policies.

Applicable CUI policies include the following and any future applicable updates to policies or laws related to CUI:

 *  Executive Order 13556 https://www.federalregister.gov/articles/2010/11/09/2010-28360/controlled-unclassified-information
 *  US 32 CFR Part 2002 https://www.govinfo.gov/content/pkg/CFR-2017-title32-vol6/pdf/CFR-2017-title32-vol6-part2002.pdf
 *  NIST SP 800-171 https://nvlpubs.nist.gov/nistpubs/SpecialPublications/NIST.SP.800-171r1.pdf
 *  NIST SP 800-171A https://doi.org/10.6028/NIST.SP.800-171A
 *  CUI Marking Handbook https://www.archives.gov/files/cui/20161206-cui-marking-handbook-v1-1.pdf
 *  CUI Registry - Health Information Category https://www.archives.gov/cui/registry/category-detail/health-info
 *  CUI Registry: Limited Dissemination Controls https://www.archives.gov/cui/registry/limited-dissemination
 *  CUI Policy and Guidance https://www.archives.gov/cui/registry/policy-guidance


Code: DENTPRG
Display: dental program
Definition:
**Definition:** A public or government health program that administers and funds coverage for dental care to assist program eligible who meet financial and health status criteria.


Code: MENTPRG
Display: mental health program
Definition:
**Definition:** Government administered and funded mental health program for beneficiaries meeting financial and mental health status criteria. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors.

**Example:** In the U.S., states receive funding for substance use programs from the Substance Abuse Mental Health Administration (SAMHSA).


Code: SAFNET
Display: safety net clinic program
Definition:
**Definition:** Government administered and funded program to support provision of care to underserved populations through safety net clinics.

**Example:** In the U.S., safety net providers such as federally qualified health centers (FQHC) receive funding under PHSA Section 330 grants administered by the Health Resources and Services Administration.


Code: SUBPRG
Display: substance use program
Definition:
**Definition:** Government administered and funded substance use program for beneficiaries meeting financial, substance use behavior, and health status criteria. Beneficiaries may be required to enroll as a result of legal proceedings. Administration, funding levels, eligibility criteria, covered benefits, provider types, and financial participation are typically set by a regulatory process. Payer responsibilities for administering the program may be delegated to contractors.

**Example:** In the U.S., states receive funding for substance use programs from the Substance Abuse Mental Health Administration (SAMHSA).


Code: ALGY
Display: Allergy Alert
Definition:
Proposed therapy may be inappropriate or contraindicated because of a recorded patient allergy to the proposed product. (Allergies are immune based reactions.)


Code: INT
Display: Intolerance Alert
Definition:
Proposed therapy may be inappropriate or contraindicated because of a recorded patient intolerance to the proposed product. (Intolerances are non-immune based sensitivities.)


Code: NOMOU
Display: no disclosure without MOU
Definition:
Prohibition on disclosure without an interagency service agreement or memorandum of understanding (MOU).


Code: NOPAT
Display: no disclosure to patient, family or caregivers without attending provider's authorization
Definition:
Prohibition on disclosing information to patient, family or caregivers without attending provider's authorization.

*Usage Note:* The information may be labeled with the ActInformationSensitivity TBOO code, triggering application of this RefrainPolicy code as a handling caveat controlling access.

Maps to FHIR NOPAT: Typically, this is used on an Alert resource, when the alert records information on patient abuse or non-compliance.

FHIR print name is "keep information from patient". Maps to the French realm - code: INVISIBLE\_PATIENT.

 *  displayName: Document non visible par le patient
 *  codingScheme: 1.2.250.1.213.1.1.4.13

French use case: A label for documents that the author chose to hide from the patient until the content can be disclose to the patient in a face to face meeting between a healthcare professional and the patient (in French law some results like cancer diagnosis or AIDS diagnosis must be announced to the patient by a healthcare professional and should not be find out by the patient alone).


Code: NOPERSISTP
Display: no collection beyond purpose of use
Definition:
Prohibition on collection of the information beyond time necessary to accomplish authorized purpose of use is prohibited.


Code: NORELINK
Display: no relinking
Definition:
Prohibition on associating de-identified or pseudonymized information with other information in a manner that could or does result in disclosing information intended to be masked.


Code: WELLREMLREV
Display: wellness reminder list review
Definition:
**Description:** A person reviews a list of wellness or preventive care reminders for a given patient.


Code: MAXOCCURS
Display: repetitions above maximum
Definition:
**Description:**The number of repeating elements is above the maximum number of repetitions allowed.


Code: MINOCCURS
Display: repetitions below minimum
Definition:
**Description:**The number of repeating elements is below the minimum number of repetitions allowed.


Code: RSDID
Display: de-identified information access
Definition:
**Definition:** Consent to have de-identified healthcare information in an electronic health record that is accessed for research purposes, but without consent to re-identify the information under any circumstance.


Code: RSREID
Display: re-identifiable information access
Definition:
**Definition:** Consent to have de-identified healthcare information in an electronic health record that is accessed for research purposes re-identified under specific circumstances outlined in the consent.

**Example::** Where there is a need to inform the subject of potential health issues.


Code: RFC
Display: Refill - Complete
Definition:
A refill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets.)


Code: RFP
Display: Refill - Part Fill
Definition:
A refill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.)


Code: RFS
Display: refill partial strength
Definition:
A fill against an order that has already been filled (or partially filled) at least once and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).


Code: RFCS
Display: refill complete partial strength
Definition:
A refill where the quantity supplied is equal to one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a complete fill would be for the full 90 tablets.) and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).


Code: RFFS
Display: refill partial strength (first fill this facility)
Definition:
The first fill against an order that has already been filled at least once at another facility and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).


Code: RFPS
Display: refill part fill partial strength
Definition:
A refill where the quantity supplied is less than one full repetition of the ordered amount. (e.g. If the order was 90 tablets, 3 refills, a partial fill might be for only 30 tablets.) and where the strength supplied is less than the ordered strength (e.g. 10mg for an order of 50mg where a subsequent fill will dispense 40mg tablets).


Code: RALG
Display: Related Allergy Alert
Definition:
Proposed therapy may be inappropriate or contraindicated because of a recorded patient allergy to a cross-sensitivity related product. (Allergies are immune based reactions.)


Code: RAR
Display: Related Prior Reaction Alert
Definition:
Proposed therapy may be inappropriate or contraindicated because of a recorded prior adverse reaction to a cross-sensitivity related product.


Code: RINT
Display: Related Intolerance Alert
Definition:
Proposed therapy may be inappropriate or contraindicated because of a recorded patient intolerance to a cross-sensitivity related product. (Intolerances are non-immune based sensitivities.)


Code: SECALTINTOBS
Display: security alteration integrity observation
Definition:
Type of security metadata observation made about the alteration integrity of an IT resource (data, information object, service, or system capability), which indicates the mechanism used for authorized transformations of the resource.

**Examples:** Types of security alteration integrity observation metadata, which may value the observation with a code used to indicate the mechanism used for authorized transformation of an IT resource, including:

 *  translation
 *  syntactic transformation
 *  semantic mapping
 *  redaction
 *  masking
 *  pseudonymization
 *  anonymization


Code: SECDATINTOBS
Display: security data integrity observation
Definition:
Type of security metadata observation made about the data integrity of an IT resource (data, information object, service, or system capability), which indicates the security mechanism used to preserve resource accuracy and consistency. Data integrity is defined by ISO 22600-23.3.21 as: "The property that data has not been altered or destroyed in an unauthorized manner", and by ISO/IEC 2382-8: The property of data whose accuracy and consistency are preserved regardless of changes made."

**Examples:** Types of security data integrity observation metadata, which may value the observation, include cryptographic hash function and digital signature.


