TEMPLATE Congenital syphilis case investigation form (Congenital syphilis case investigation form)

TEMPLATE IDCongenital syphilis case investigation form
ConceptCongenital syphilis case investigation form
DescriptionNot Specified
PurposeNot Specified
References
Authorsname: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2023-09-04
Other Details Languagename: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2023-09-04
Other Details (Language Independent)
  • Sem Ver: 157.0.0
  • MD5-CAM-1.0.1: 098d4af23219e57c32e93eedcc20fbed
  • PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC
  • Original Language: ISO_639-1::en
Language useden
Citeable Identifier1013.26.977
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
2024 12 29 Congenital syphilis case investigation form2024 12 29 Congenital syphilis case investigation form: Document to communicate information to others, commonly in response to a request from another party.
Infectious disease investigation metadataInfectious disease investigation metadata: Infectious disease investigation metadata.
DataData: *
Notified diseaseNotified disease: The name of the disease under investigation.
  • Congenital Syphilis
Notification IDNotification ID: The unique identifier for the notification that triggered this infectious disease investigation.
The investigation ID and the notification ID may be identical if both the notification and investigation are carried out within the same system.
Investigation IDInvestigation ID: The unique identifier for this infectious disease investigation.
The investigation ID and the notification ID may be identical if both the notification and investigation are carried out within the same system.
Date identifiedDate identified: The date when the infection was first identified by a clinician or notifier.
Epidemiological week of onsetEpidemiological week of onset: Standardised way to identify the week of onset of symptoms.
Also known as 'epi week'.
Epidemiological week of notificationEpidemiological week of notification: Standardised way to identify the week of notification to public health authorities.
Also known as 'epi week'.
Date of notificationDate of notification: Details about the person who notified public health authorities about the infectious disease case.
Person - notifying individualPerson - notifying individual: An individual human being.
Structured name of a person - coreStructured name of a person - core: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
Professional license numberProfessional license number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Professional groupProfessional group: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Contact Investigator
  • Data Entry Clerk
  • Epidemiologist
  • Lab Technician
  • Public Health Inspector
  • Public Health Nurse
  • Medical Doctor
  • Medical Officer of Health
  • Medical Technologist
  • Nurse (not PHN)
  • Surveillance Officer
  • Social Worker
PositionPosition: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
Healthcare facilityHealthcare facility: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
IdentifierIdentifier: Identifier associated with the organisation.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the ID data type contains multiple subcomponents for recording the ID value, type, issuer and assigner.
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Detection methodDetection method: Method of detection of the index disease.
Person - investigating officerPerson - investigating officer: An individual human being.
Structured name of a person - coreStructured name of a person - core: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
Professional license numberProfessional license number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Professional groupProfessional group: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
PositionPosition: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
OrganisationOrganisation: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
Date investigation initiatedDate investigation initiated: The date when the investigator commenced the investigation.
Person - clinicianPerson - clinician: An individual human being.
Structured name of a person - coreStructured name of a person - core: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
Professional license numberProfessional license number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Professional groupProfessional group: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
PositionPosition: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
OrganisationOrganisation: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
Healthcare facilityHealthcare facility: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
IdentifierIdentifier: Identifier associated with the organisation.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the ID data type contains multiple subcomponents for recording the ID value, type, issuer and assigner.
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Date investigation completedDate investigation completed: The date when the investigator finished the investigation report.
Date submitted to MO(H)Date submitted to MO(H): The date when the investigator submitted the investigation report for review.
MO(H) sign offMO(H) sign off: Details about review, sign off or approval by local or regional clinical authorities.
Date received for reviewDate received for review: The date when the reviewer received the investigation for review.
Person - public health officialPerson - public health official: An individual human being.
Structured name of a person - coreStructured name of a person - core: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
Professional license numberProfessional license number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Professional groupProfessional group: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
PositionPosition: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
OrganisationOrganisation: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
ParishParish: Name of the local health region.
CommentComment: Narrative description about the investigation report.
Date review completedDate review completed: The date when the reviewer completed the review of the investigation.
Date submitted to NSUDate submitted to NSU: The date on which the investigation was submitted to public health authorities.
Infant profileInfant profile: A generic section header which should be renamed in a template to suit a specific clinical context.
Case demographic informationCase demographic information: A generic section header which should be renamed in a template to suit a specific clinical context.
Child demographicsChild demographics: A container archetype used to hold demographic-related EHR CLUSTER archetypes.
Data
Person - child patientPerson - child patient: An individual human being.
Structured name of a person - fullStructured name of a person - full: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
Medical Record Number (MRN)Medical Record Number (MRN): Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Jamaica Digital Health IDJamaica Digital Health ID: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
National Identification Number (NIN)National Identification Number (NIN): Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Birth certificate numberBirth certificate number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Student Registration NumberStudent Registration Number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Taxpayer Registration Number (TRN)Taxpayer Registration Number (TRN): Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Drivers licenceDrivers licence: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Passport numberPassport number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
National Insurance Scheme NumberNational Insurance Scheme Number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Address - Local + GISAddress - Local + GIS: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Geolocation codeGeolocation code: Unique identifier that represents a precise geographical location.
Also known as a geocode. For example: GPS coordinates concatenating longitude, latitude +/-altitude; Open Location Code or Plus Code; Universal Transverse Mercator (UTM); and geohash.
LatitudeLatitude: Horizontal (y) coordinate of a geolocation for the address.
Latitude is represented by positive values north of the equator and negative values south of the equator. For example the latitude of the Eiffel Tower is 48.858093.
-90..90 °
LongitudeLongitude: Horizontal (x) coordinate of a geolocation for the address.
Longitude is represented by negative values west of Prime Meridian and positive values east of Prime Meridian. For example the longitude of the Eiffel Tower is 2.294694.
-180..180 °
Map URLMap URL: Link to a location on an online map.
For example: a location on a Google or iOS map.
Phone - home landlinePhone - home landline: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Personal use 
Phone - personal mobilePhone - personal mobile: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Personal use 
EmailEmail: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
CommentComment: Additional narrative about the electronic communication not captured in other fields.
Person - nameless infant patientPerson - nameless infant patient: An individual human being.
LabelLabel: A label for the individual.
For example: 'Neighbour in the house with the red door'.
  • Baby of
Structured name of woman - full + maidenStructured name of woman - full + maiden: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
Maiden nameMaiden name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
Medical Record Number (MRN)Medical Record Number (MRN): Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Jamaica Digital Health IDJamaica Digital Health ID: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Address - Local + GISAddress - Local + GIS: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Geolocation codeGeolocation code: Unique identifier that represents a precise geographical location.
Also known as a geocode. For example: GPS coordinates concatenating longitude, latitude +/-altitude; Open Location Code or Plus Code; Universal Transverse Mercator (UTM); and geohash.
LatitudeLatitude: Horizontal (y) coordinate of a geolocation for the address.
Latitude is represented by positive values north of the equator and negative values south of the equator. For example the latitude of the Eiffel Tower is 48.858093.
-90..90 °
LongitudeLongitude: Horizontal (x) coordinate of a geolocation for the address.
Longitude is represented by negative values west of Prime Meridian and positive values east of Prime Meridian. For example the longitude of the Eiffel Tower is 2.294694.
-180..180 °
Map URLMap URL: Link to a location on an online map.
For example: a location on a Google or iOS map.
Phone - home landlinePhone - home landline: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Personal use 
Phone - personal mobilePhone - personal mobile: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Personal use 
EmailEmail: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
CommentComment: Additional narrative about the electronic communication not captured in other fields.
Birth summaryBirth summary: Overview or summary record of the pregnancy and birth of an individual.
Data
Date of birthDate of birth: The date/time of birth of the individual.
May also be used to record the assumed or agreed date/time of birth for operational purposes, if the actual date/time is not formally recorded. Possible alternatives for the date/time of birth of the individual can be recorded using the CLUSTER.DOB_alternative archetype 'Date of birth details' SLOT. Partial dates are allowed.
Place of birthPlace of birth: Simple representation about the place of birth.
This data element provides the opportunity for simple detail about the place of birth, such as the city, region, town, or suburb within the identified 'Country of birth'. For example: Kingston (Jamaica); Manhattan (USA); or Box Hill (Australia).
Age assertion - infantAge assertion - infant: A statement about the age of an individual at a point in time.
Data
Point in time eventPoint in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Data
Chronological ageChronological age: The age of an individual at the event time, calculated from date of birth.
In most use cases the DV_DURATION data type is used to record the Chronological age. The DV_INTERVAL_DURATION is used for recording a structured age interval in cases where there's uncertainty about the individual's exact age. The DV_QUANTITY data type is used for recording a decimal age in years or mean Julian years (365.25 days). The DV_TEXT data type is used for recording a textual representation of the individual's age, or age category often found in questionnaires. For example: 'P3M2W', '0,2884615384615385 a_j', '3 months 2 weeks' or '31-40 years' or 'Teenager'.
PT1H..P51W
Sex & gender - newbornSex & gender - newborn: Details about the gender of an individual.
Data
Sex assigned at birthSex assigned at birth: The sex of an individual determined by anatomical characteristics observed and registered at birth.
For example: 'Male', 'Female', 'Intersex'. Coding with a terminology is recommended, where possible. Use the element 'Comment' or the SLOT 'Details' if needed to register more specific details of the individuals gender.
  • Male
  • Female
  • Indeterminate
Clinical profileClinical profile: A generic section header which should be renamed in a template to suit a specific clinical context.
Clinical screeningClinical screening: A generic section header which should be renamed in a template to suit a specific clinical context.
Symptom/sign screeningSymptom/sign screening: Series of questions and associated answers used to screen for symptoms or signs.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Any symptoms or signs?Any symptoms or signs?: Is there a history of any symptoms or signs relevant for the screening purpose?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Onset of illnessOnset of illness: Timing of the inital recognition of any symptom or sign relevant for the screening purpose.
The 'Onset' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture the onset of symptoms or signs. The specific and intended semantics can be further clarified in a template. For example: Date/time for the date the symptom started. Interval of date/time for a period of time eg. between 1940 and 1942. Text for descriptions like 'Immediately after the operation', or 'Up to one week ago', 'Up to two weeks ago', 'Three weeks ago'. Duration for the individual's age at the onset. Interval of Duration for the approximate age of the individual at the time of onset.
Specific symptom/signSpecific symptom/sign: Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose.
Symptom/sign nameSymptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name.
Coding of the 'Symptom/sign name' with a terminology is preferred, where possible.
  • Generalized lymphadenopathy
  • Vesiculobullous rash
  • Other rashes
  • Pneumonia
  • Neurological symptoms
  • Hepatosplenomegaly
  • Mucous patches
  • Snuffles
  • Jaundice
  • Anaemia
  • Failure to thrive
  • Cataract
  • Desquamation of feet
  • Bony deformity
Presence?Presence?: Is there a history of the specific symptom or sign being present?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date of onsetDate of onset: Indication of timing related to the specific symptom or sign.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the specific symptom or sign occured. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for when the specific symptom or sign; the interval of time during which the specific symptom or sign occured; the duration of the specific symptom or sign; the age of the individual at the time of the specific symptom or sign occured; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
DurationDuration: Indication of timing related to the specific symptom or sign.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the specific symptom or sign occured. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for when the specific symptom or sign; the interval of time during which the specific symptom or sign occured; the duration of the specific symptom or sign; the age of the individual at the time of the specific symptom or sign occured; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
  •  Duration
  •  Interval of Duration
  •  Date/Time
  •  Interval of Date/Time
  •  Text
Other symptom/signOther symptom/sign: Details about a specific symptom or sign or grouping of symptoms or signs relatevant for the screening purpose.
Symptom/sign nameSymptom/sign name: Identification of a specific symptom or sign or grouping of symptoms or signs, by name.
Coding of the 'Symptom/sign name' with a terminology is preferred, where possible.
Presence?Presence?: Is there a history of the specific symptom or sign being present?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
Date of onsetDate of onset: Indication of timing related to the specific symptom or sign.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the specific symptom or sign occured. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for when the specific symptom or sign; the interval of time during which the specific symptom or sign occured; the duration of the specific symptom or sign; the age of the individual at the time of the specific symptom or sign occured; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
DurationDuration: Indication of timing related to the specific symptom or sign.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when the specific symptom or sign occured. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for when the specific symptom or sign; the interval of time during which the specific symptom or sign occured; the duration of the specific symptom or sign; the age of the individual at the time of the specific symptom or sign occured; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Clinical contextClinical context: A generic section header which should be renamed in a template to suit a specific clinical context.
Birth summaryBirth summary: Overview or summary record of the pregnancy and birth of an individual.
Data
Birth detailBirth detail: A subset of persistent or summary information about the pregnancy and birth of an infant, selected for utility of use within both the maternal and infant health records.
Birth outcomeBirth outcome: Outcome of the pregnancy for the identified infant or fetus.
  • Live birth 
  • Still birth 
Gestational age at birthGestational age at birth: The length of the pregnancy at the time of delivery of the infant.
The value for this data element will usually, but not always, be identical to the 'Pregnancy duration' data element within the EVALUATION.pregnancy_summary in the maternal record. It may also be derived using the 'Agreed date' data element within the EVALUATION.estimated_date_delivery archetype in the maternal record. Usually estimated by Naegele's rule or by ultrasound scan.
P0W..P52W Week
Birth category by gestationBirth category by gestation: Category of birth based on the duration of the pregnancy at birth.
  • Pre-term 
  • Term 
  • Post-term 
Infant measurementsInfant measurements: A generic section header which should be renamed in a template to suit a specific clinical context.
Body weightBody weight: Measurement of the body weight of an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
WeightWeight: The weight of the individual.
0..1000; 0..2000; 0..1000000
Units:
  • kg
  • lbm
  • g
BirthBirth: Usually the first weight, measured soon after birth. This event will only be used once per health record .
Data
WeightWeight: The weight of the individual.
0..1000; 0..2000; 0..1000000
Units:
  • kg
  • lbm
  • g
CommentComment: Additional narrative about the measurement of Body weight, not captured in other fields.
Data
WeightWeight: The weight of the individual.
0..1000; 0..2000; 0..1000000
Units:
  • kg
  • lbm
  • g
CommentComment: Additional narrative about the measurement of Body weight, not captured in other fields.
State
State of dressState of dress: Description of the state of dress of the person at the time of weighing.
  • Naked 
  • Nappy/diaper 
  • Lightly clothed/underwear 
  • Fully clothed, without shoes 
  • Fully clothed, including shoes 
Confounding factorsConfounding factors: Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
State
State of dressState of dress: Description of the state of dress of the person at the time of weighing.
  • Naked 
  • Nappy/diaper 
  • Lightly clothed/underwear 
  • Fully clothed, without shoes 
  • Fully clothed, including shoes 
Confounding factorsConfounding factors: Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
Body weight for ageBody weight for age: Details about parameters plotted on a growth chart to allow monitoring of a child's growth over time, relative to a reference population.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Growth indicatorGrowth indicator: The name of the growth parameter.
  • Weight-for-age 
Z-score categoryZ-score category: The category or grouping of the Z score.
For example: a choice between <-3, <-2, or Normal.
Protocol
Growth reference chartGrowth reference chart: Specifies the standard or syndrome-specific reference charts used to calculate the growth indicator data.
For example, for a typical height assessment, 'WHO' might be used, whereas for children diagnosed with Turner Syndrome, the 'Turner' standard would be applicable (see the Royal College of Paediatrics and Child Health API (https://growth.rcpch.ac.uk/).
LengthLength: Height, or body length, is measured from crown of head to sole of foot.
Height is measured with the individual in a standing position and body length in a recumbent position.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
LengthLength: The length of the body from crown of head to sole of foot.
0..1000; 0..250
Units:
  • cm
  • in
BirthBirth: Usually the first length measurement, recorded soon after birth. This event will only be used once per health record .
Data
Height/LengthHeight/Length: The length of the body from crown of head to sole of foot.
0..1000; 0..250
Units:
  • cm
  • in
CommentComment: Additional narrative about the measurement, not captured in other fields.
Data
Height/LengthHeight/Length: The length of the body from crown of head to sole of foot.
0..1000; 0..250
Units:
  • cm
  • in
CommentComment: Additional narrative about the measurement, not captured in other fields.
State
PositionPosition: Position of individual when measured.
  • Standing 
  • Lying 
Assumed value: Standing
Confounding factorsConfounding factors: Narrative description of any issues or factors that may impact on the measurement.
For example: noting of amputation.
State
PositionPosition: Position of individual when measured.
  • Standing 
  • Lying 
Assumed value: Standing
Confounding factorsConfounding factors: Narrative description of any issues or factors that may impact on the measurement.
For example: noting of amputation.
Body length for ageBody length for age: Details about parameters plotted on a growth chart to allow monitoring of a child's growth over time, relative to a reference population.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Growth indicatorGrowth indicator: The name of the growth parameter.
  • Length/height-for-age 
Z-score categoryZ-score category: The category or grouping of the Z score.
For example: a choice between <-3, <-2, or Normal.
Head circumferenceHead circumference: The measurement of the longest distance around the head.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Head circumferenceHead circumference: The measurement of the longest distance around the head.
0..100; 0..40
Units:
  • cm
  • in
BirthBirth: The first measurement of head circumference that is recorded soon after birth. This event should only be used once per record.
Data
Head circumferenceHead circumference: The measurement of the longest distance around the head.
0..100; 0..40
Units:
  • cm
  • in
CommentComment: Additional narrative about the head circumference not captured in other fields.
Data
Head circumferenceHead circumference: The measurement of the longest distance around the head.
0..100; 0..40
Units:
  • cm
  • in
CommentComment: Additional narrative about the head circumference not captured in other fields.
State
Confounding factorsConfounding factors: Narrative descripiton of any issues or factors that may impact on the measurement.
For example: 'uncooperative child','caput & moulding post birth' and 'haematoma'.
State
Confounding factorsConfounding factors: Narrative descripiton of any issues or factors that may impact on the measurement.
For example: 'uncooperative child','caput & moulding post birth' and 'haematoma'.
Head circumference for ageHead circumference for age: Details about parameters plotted on a growth chart to allow monitoring of a child's growth over time, relative to a reference population.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Growth indicatorGrowth indicator: The name of the growth parameter.
  • Head circumference-for-age 
Z-score categoryZ-score category: The category or grouping of the Z score.
For example: a choice between <-3, <-2, or Normal.
Clinical notesClinical notes: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Clinical notesClinical notes: The summary, assessment, conclusions or evaluation of the clinical findings.
Clinical managementClinical management: A generic section header which should be renamed in a template to suit a specific clinical context.
Laboratory test screeningLaboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specimen taken?Specimen taken?: Is there a history of any diagnostic tests or investigations related to the screening purpose?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Blood specimenBlood specimen: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test nameTest name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Non-treponemal screening test
  • Treponemal confirmation test
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date/time sent to laboratoryDate/time sent to laboratory: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Date/time result reportedDate/time result reported: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Specimen collection detailsSpecimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Specimen typeSpecimen type: The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
  • Blood
Date/time received by laboratoryDate/time received by laboratory: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collectedDate/time collected: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
Non-treponemal screening testNon-treponemal screening test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • VDRL
  • TRUST
  • RPR
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Weakly reactive/Borderline
  • Reactive/Positive
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Treponemal confirmation testTreponemal confirmation test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • MHA-Tp
  • FTA-ABS
  • TPPA
  • TPHA
Microbial targetMicrobial target: The name of the microorganism associated with the antibody target, if relevant.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2.
  • Treponema pallidum
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Reactive/Positive
  • Indeteminate/Borderline
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Molecular microbial test findingsMolecular microbial test findings: The result of a laboratory test for the detection and identification of specific micro-organism DNA or RNA in a specimen, using nucleic acid probes.
Test nameTest name: Name of the molecular test carried out.
Coding with an external terminology is recommended, if available. For example: PCR for Mycobacterium tuberculosis or SARS-CoV-2.
Microbial targetMicrobial target: The name of the microorganism being detected.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2, Mycobacterium tuberculosis, or Candida albicans.
PresencePresence: Statement about detection of the identified microorganism in the specimen.
  • Detected 
  • Not detected 
  • Indeterminate 
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified microorganism in the specimen.
Units: copies/mL
CommentComment: Additional narrative about the test finding not captured in other fields.
CSF specimenCSF specimen: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test nameTest name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Non-treponemal screening test
  • Treponemal confirmation test
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date/time sent to laboratoryDate/time sent to laboratory: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Date/time result reportedDate/time result reported: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Specimen collection detailsSpecimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Specimen typeSpecimen type: The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
  • CSF
Date/time received by laboratoryDate/time received by laboratory: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collectedDate/time collected: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
Non-treponemal screening testNon-treponemal screening test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • VDRL
  • TRUST
  • RPR
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Weakly reactive/Borderline
  • Reactive/Positive
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Treponemal confirmation testTreponemal confirmation test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • MHA-Tp
  • FTA-ABS
  • TPPA
  • TPHA
Microbial targetMicrobial target: The name of the microorganism associated with the antibody target, if relevant.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2.
  • Treponema pallidum
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Reactive/Positive
  • Indeteminate/Borderline
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Imaging examination screening - JMImaging examination screening - JM: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Any imaging?Any imaging?: Is there a history of any diagnostic tests or investigations related to the screening purpose?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Specific imagingSpecific imaging: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Study nameStudy name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Long bone Xrays
  • Abdominal ultrasound
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date of studyDate of study: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
FindingsFindings: Brief description, summary or interpretation of the investigation outcome.
For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings. In that situation, nest an appropriate CLUSTER archetype within the following 'Additional details' SLOT.
CommentComment: Additional narrative about the diagnostic investigation test not captured in other fields.
Medication screeningMedication screening: Series of questions and associated answers used to screen for the use of medications.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific medicationSpecific medication: Details about a specified medication or grouping of medications relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific medications or groupings of medication.
Medication nameMedication name: Name of medication or grouping of medication.
For example: 'alendronic acid', 'anti osteoporosis medications' or 'bisphosphonates'. Coding of the 'Medication name' with a terminology is preferred, where possible.
  • Benzathine benzylpenicillin
GivenGiven: Is there a history of use of a specific medication or group of medications?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. For example an alternative valueset using the DV_TEXT datatype can be: Currently using [The individual currently uses the specific medication either on a regular basis or as required.] Never used [The individual has never used the specific medication.] Used in the past [The individual has used the specific medication in the past, but isn't currently using it.] Unknown [It is not known whether the individual uses or has used the specific medication.]
  • Yes 
  • No 
  • Unknown 
CommentComment: Additional narrative about the specific medication question, not captured in other fields.
BPG administrationBPG administration: An assertion about the current use of a single medication by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication nameMedication name: Name of the medication.
It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'.
  • Benzathine benzylpenicillin
Dose and frequencyDose and frequency: Complete narrative description about how the ordered item is to be used.
Route of administrationRoute of administration: The route by which the medication is administrated into the body.
For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible.
  • Intramuscular
CommentComment: Additional narrative about the medication statement not captured in other fields.
First administeredFirst administered: The date and time when the medication was first taken by, or administered to, the individual.
Number of doses administeredNumber of doses administered: The total number of doses administered.
For example: 1 stat dose of prophylactic antibiotics; or 10 doses in an antibiotic course over 5 days.
Management notesManagement notes: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Actions takenActions taken: The summary, assessment, conclusions or evaluation of the clinical findings.
Social profileSocial profile: A generic section header which should be renamed in a template to suit a specific clinical context.
Social networkSocial network: Group of individuals connected by social interactions and personal relationships.
Data
Person - next of kinPerson - next of kin: An individual human being.
Structured name of a person - fullStructured name of a person - full: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
RoleRole: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Next of kin
RelationshipRelationship: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Mother
  • Father
  • Brother
  • Sister
  • Cousin
  • Aunt
  • Uncle
  • Grandmother
  • Grandfather
  • Caregiver
  • Guardian
  • Legal Guardian
  • Husband
  • Wife
  • Friend
  • Son
  • Daughter
  • Spiritual advisor
  • Worker in religion
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
Phone - unspecified number/sPhone - unspecified number/s: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Business use 
  • Personal use 
  • Both business and personal use 
Person - motherPerson - mother: An individual human being.
Structured name of woman - full + maidenStructured name of woman - full + maiden: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
Maiden nameMaiden name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
RelationshipRelationship: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Mother
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
Phone - unspecified number/sPhone - unspecified number/s: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Business use 
  • Personal use 
  • Both business and personal use 
Person - fatherPerson - father: An individual human being.
Structured name of a person - fullStructured name of a person - full: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
RelationshipRelationship: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Father
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
Phone - unspecified number/sPhone - unspecified number/s: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Business use 
  • Personal use 
  • Both business and personal use 
Person - guardianPerson - guardian: An individual human being.
Structured name of a person - fullStructured name of a person - full: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
RoleRole: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Guardian
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
Phone - unspecified number/sPhone - unspecified number/s: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Business use 
  • Personal use 
  • Both business and personal use 
OutcomeOutcome: A generic section header which should be renamed in a template to suit a specific clinical context.
Vital statusVital status: Status of an individual as alive or dead.
Data
Any point in time eventAny point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Data
Vital statusVital status: Whether an individual is alive or dead.
Usually only relevant at a specified point in time. For example: record as alive or dead at the time of recording information within a disease registry.
  • Alive 
  • Dead 
  • Unknown 
Death summaryDeath summary: Summary information about the circumstances and context of the death of an individual, excluding the cause(s) of death.
Data
Date of deathDate of death: The known, or assumed, date and time of death.
Partial dates and an absence of time of death are allowed, if necessary. For example: based on findings pertaining to examination of the body and the pathologist's reconstruction of time of death based on post-mortem changes, temperature, etc. May also be known as DOD (date of death). If more than one 'Date of death alternatives' have been proposed, this data element could be renamed in a template as the 'Confirmed/Agreed date of death'.
Place of deathPlace of death: The simple name, address or landmark of the place where the individual died.
For example: 'City Hospital'; 'Mother's house'; or 'Mt Vesuvius crater'; or 'Corner of Smith & Brown Streets'. This data element has multiple occurrences to allow more than one level of detail about the place of death, such as recording both 'City Hospital' and 'Ward 6 North'.
Maternal profileMaternal profile: A generic section header which should be renamed in a template to suit a specific clinical context.
Mother demographic informationMother demographic information: A generic section header which should be renamed in a template to suit a specific clinical context.
NameName: A container archetype used to hold demographic-related EHR CLUSTER archetypes.
Data
Person - motherPerson - mother: An individual human being.
Structured name of woman - full + maidenStructured name of woman - full + maiden: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
Maiden nameMaiden name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
Medical record numberMedical record number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
RelationshipRelationship: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Mother
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
Phone - unspecified number/sPhone - unspecified number/s: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Business use 
  • Personal use 
  • Both business and personal use 
Date of birthDate of birth: Overview or summary record of the pregnancy and birth of an individual.
Data
Date of birthDate of birth: The date/time of birth of the individual.
May also be used to record the assumed or agreed date/time of birth for operational purposes, if the actual date/time is not formally recorded. Possible alternatives for the date/time of birth of the individual can be recorded using the CLUSTER.DOB_alternative archetype 'Date of birth details' SLOT. Partial dates are allowed.
Age assertionAge assertion: A statement about the age of an individual at a point in time.
Data
Point in time eventPoint in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Data
Chronological ageChronological age: The age of an individual at the event time, calculated from date of birth.
In most use cases the DV_DURATION data type is used to record the Chronological age. The DV_INTERVAL_DURATION is used for recording a structured age interval in cases where there's uncertainty about the individual's exact age. The DV_QUANTITY data type is used for recording a decimal age in years or mean Julian years (365.25 days). The DV_TEXT data type is used for recording a textual representation of the individual's age, or age category often found in questionnaires. For example: 'P3M2W', '0,2884615384615385 a_j', '3 months 2 weeks' or '31-40 years' or 'Teenager'.
P1M..P200Y
Units:
  • Year
  • Month
Occupation summaryOccupation summary: Summary or persistent information about an individual's current and past jobs and/or roles.
Data
Employment statusEmployment status: Statement about the individual's current employment.
For example: employed; unemployed; or not in labour force. Coding with a terminology is desirable, where possible. Detail about each occupation can be recorded within the CLUSTER.occupation_record archetype.
  • Employed
  • Unemployed
  • Unknown
Occupation recordOccupation record: A single job or role carried out by an individual during a specified period of time.
OccupationOccupation: The main job title or the role of the individual.
For example: Chief Executive Officer; Carer; or Student. Each of these job titles or roles may be comprised of multiple duties.
  • Armed Forces Occupations (All Ranks)
  • Soldier
  • Custos
  • Governor General
  • Leader, Opposition (Governmental)
  • Opposition Leader
  • Prime Minister
  • Cabinet Minister
  • Constituency Representative
  • Government Minister
  • Member of Parliament
  • Minister, Cabinet
  • Minister, Government
  • Minister, Opposition
  • MP
  • Opposition Minister
  • Senator
  • Attorney General
  • Solicitor General
  • Public Defender
  • Ombudsman, Political
  • Political Ombudsman
  • Chief Parliamentary Counsel
  • Legislators n.e.c.
  • Civil Service Commissioner
  • Commissioner, Civil Service
  • Financial Secretary
  • Head, Civil Service Commission
  • Permanent Secretary
  • Secretary, Financial
  • Secretary, Permanent
  • Chief Executive Officer (Governmental Department/Agency)
  • and MORE
  • [...]
Employer/SchoolEmployer/School: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
Name of Employer/SchoolName of Employer/School: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Clinical profileClinical profile: A generic section header which should be renamed in a template to suit a specific clinical context.
Current pregnancyCurrent pregnancy: A generic section header which should be renamed in a template to suit a specific clinical context.
Obstetric summaryObstetric summary: Summary or persistent information about the numbers of key obstetric events.
Data
GravidityGravidity: Number of times a woman has been pregnant, current and past, regardless of the pregnancy outcome.
Clinical systems might represent this data element by the term 'Gravida' on a clinical form.
0..100
ParityParity: Number of times a woman has given birth to a viable baby, regardless of the pregnancy outcome.
Parity includes all pregnancies that are carried after the fetus is considered viable, as defined in the 'Definition of viability data' element. Stillbirths, late abortions, and all live births are included in the assessment of Parity. In cases of multiple pregnancies, parity is only increased with birth of the last fetus.
0..100
Preterm birthsPreterm births: Number of births before term.
The definition of a preterm birth is a viable birth before 37 weeks of gestation.
0..100
MiscarriagesMiscarriages: Number of times a woman has had a miscarriage.
The definition of viability can be recorded in the Protocol.
0..100
Live birthsLive births: Number of infants born alive.
0..100
StillbirthsStillbirths: Number of stillbirths.
The definition of viability can be recorded in the Protocol.
0..100
Social networkSocial network: Group of individuals connected by social interactions and personal relationships.
Data
Living childrenLiving children: Number of children alive.
Applies to men and women alike when considered in the context of social network.
Pregnancy care summaryPregnancy care summary: Summary details about the antenatal and postnatal care received during a single pregnancy.
Data
No antenatal careNo antenatal care: *
Overall funding typeOverall funding type: Source of funding for all pregnancy care.
  • Public 
  • Private 
  • Both 
First antenatal visitFirst antenatal visit: The date of the first antenatal visit for the pregnancy overall.
Gestation at first visitGestation at first visit: Gestation at the first antenatal visit for the pregnancy overall.
Antenatal careAntenatal care: Details about an episode of antenatal care from a single healthcare provider or using a single funding type.
Use a separate instance of this repeating CLUSTER to record a single episode of care per healthcare provider or funding type.
Funding typeFunding type: Source of funding for this episode of antenatal care.
For example: public or private.
  • Public 
  • Private 
OrganisationOrganisation: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
IdentifierIdentifier: Identifier associated with the organisation.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the ID data type contains multiple subcomponents for recording the ID value, type, issuer and assigner.
RoleRole: The relationship or role of the organisation to the individual or subject of care.
For example: oncologist; palliative care home nursing service; or informal support network.
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
CommentComment: Additional narrative about the organisation not captured in other fields.
Person - clinicianPerson - clinician: An individual human being.
Structured name of a person - coreStructured name of a person - core: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
Professional license numberProfessional license number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Professional groupProfessional group: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
PositionPosition: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
OrganisationOrganisation: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
Number of visitsNumber of visits: The number of visits to the identified healthcare provider.
Total number of antenatal visitsTotal number of antenatal visits: Total number of antenatal clinic visits of all types and locations for the pregnancy overall.
Laboratory test screeningLaboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specimen taken?Specimen taken?: Is there a history of any diagnostic tests or investigations related to the screening purpose?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Syphilis screeningSyphilis screening: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test nameTest name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Non-treponemal screening test
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date/time sent to laboratoryDate/time sent to laboratory: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Date/time result reportedDate/time result reported: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Specimen collection detailsSpecimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Specimen typeSpecimen type: The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
  • Blood
Date/time received by laboratoryDate/time received by laboratory: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collectedDate/time collected: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
Non-treponemal screening testNon-treponemal screening test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • VDRL
  • TRUST
  • RPR
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Weakly reactive/Borderline
  • Reactive/Positive
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Medication screeningMedication screening: Series of questions and associated answers used to screen for the use of medications.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific medicationSpecific medication: Details about a specified medication or grouping of medications relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific medications or groupings of medication.
Medication nameMedication name: Name of medication or grouping of medication.
For example: 'alendronic acid', 'anti osteoporosis medications' or 'bisphosphonates'. Coding of the 'Medication name' with a terminology is preferred, where possible.
  • Benzathine benzylpenicillin
GivenGiven: Is there a history of use of a specific medication or group of medications?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. For example an alternative valueset using the DV_TEXT datatype can be: Currently using [The individual currently uses the specific medication either on a regular basis or as required.] Never used [The individual has never used the specific medication.] Used in the past [The individual has used the specific medication in the past, but isn't currently using it.] Unknown [It is not known whether the individual uses or has used the specific medication.]
  • Yes 
  • No 
  • Unknown 
CommentComment: Additional narrative about the specific medication question, not captured in other fields.
BPG administrationBPG administration: An assertion about the current use of a single medication by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication nameMedication name: Name of the medication.
It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'.
  • Benzathine benzylpenicillin
Dose and frequencyDose and frequency: Complete narrative description about how the ordered item is to be used.
Route of administrationRoute of administration: The route by which the medication is administrated into the body.
For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible.
  • Intramuscular
CommentComment: Additional narrative about the medication statement not captured in other fields.
First administeredFirst administered: The date and time when the medication was first taken by, or administered to, the individual.
Number of doses administeredNumber of doses administered: The total number of doses administered.
For example: 1 stat dose of prophylactic antibiotics; or 10 doses in an antibiotic course over 5 days.
Management notesManagement notes: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Actions takenActions taken: The summary, assessment, conclusions or evaluation of the clinical findings.
Previous pregnancyPrevious pregnancy: A generic section header which should be renamed in a template to suit a specific clinical context.
Laboratory test screeningLaboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Syphilis screeningSyphilis screening: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test nameTest name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Non-treponemal screening test
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date/time sent to laboratoryDate/time sent to laboratory: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Date/time result reportedDate/time result reported: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Specimen collection detailsSpecimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Specimen typeSpecimen type: The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
  • Blood
Date/time received by laboratoryDate/time received by laboratory: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collectedDate/time collected: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
Non-treponemal screening testNon-treponemal screening test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • VDRL
  • TRUST
  • RPR
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Weakly reactive/Borderline
  • Reactive/Positive
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Medication screeningMedication screening: Series of questions and associated answers used to screen for the use of medications.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific medicationSpecific medication: Details about a specified medication or grouping of medications relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific medications or groupings of medication.
Medication nameMedication name: Name of medication or grouping of medication.
For example: 'alendronic acid', 'anti osteoporosis medications' or 'bisphosphonates'. Coding of the 'Medication name' with a terminology is preferred, where possible.
  • Benzathine benzylpenicillin
GivenGiven: Is there a history of use of a specific medication or group of medications?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. For example an alternative valueset using the DV_TEXT datatype can be: Currently using [The individual currently uses the specific medication either on a regular basis or as required.] Never used [The individual has never used the specific medication.] Used in the past [The individual has used the specific medication in the past, but isn't currently using it.] Unknown [It is not known whether the individual uses or has used the specific medication.]
  • Yes 
  • No 
  • Unknown 
CommentComment: Additional narrative about the specific medication question, not captured in other fields.
BPG administrationBPG administration: An assertion about the current use of a single medication by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication nameMedication name: Name of the medication.
It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'.
  • Benzathine benzylpenicillin
Dose and frequencyDose and frequency: Complete narrative description about how the ordered item is to be used.
Route of administrationRoute of administration: The route by which the medication is administrated into the body.
For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible.
  • Intramuscular
CommentComment: Additional narrative about the medication statement not captured in other fields.
First administeredFirst administered: The date and time when the medication was first taken by, or administered to, the individual.
Number of doses administeredNumber of doses administered: The total number of doses administered.
For example: 1 stat dose of prophylactic antibiotics; or 10 doses in an antibiotic course over 5 days.
Non-pregnant contextNon-pregnant context: A generic section header which should be renamed in a template to suit a specific clinical context.
Laboratory test screeningLaboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Syphilis screeningSyphilis screening: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test nameTest name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Non-treponemal screening test
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date/time sent to laboratoryDate/time sent to laboratory: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Date/time result reportedDate/time result reported: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Specimen collection detailsSpecimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Specimen typeSpecimen type: The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
  • Blood
Date/time received by laboratoryDate/time received by laboratory: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collectedDate/time collected: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
Non-treponemal screening testNon-treponemal screening test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • VDRL
  • TRUST
  • RPR
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Weakly reactive/Borderline
  • Reactive/Positive
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Medication screeningMedication screening: Series of questions and associated answers used to screen for the use of medications.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific medicationSpecific medication: Details about a specified medication or grouping of medications relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific medications or groupings of medication.
Medication nameMedication name: Name of medication or grouping of medication.
For example: 'alendronic acid', 'anti osteoporosis medications' or 'bisphosphonates'. Coding of the 'Medication name' with a terminology is preferred, where possible.
  • Benzathine benzylpenicillin
GivenGiven: Is there a history of use of a specific medication or group of medications?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. For example an alternative valueset using the DV_TEXT datatype can be: Currently using [The individual currently uses the specific medication either on a regular basis or as required.] Never used [The individual has never used the specific medication.] Used in the past [The individual has used the specific medication in the past, but isn't currently using it.] Unknown [It is not known whether the individual uses or has used the specific medication.]
  • Yes 
  • No 
  • Unknown 
CommentComment: Additional narrative about the specific medication question, not captured in other fields.
BPG administrationBPG administration: An assertion about the current use of a single medication by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication nameMedication name: Name of the medication.
It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'.
  • Benzathine benzylpenicillin
Dose and frequencyDose and frequency: Complete narrative description about how the ordered item is to be used.
Route of administrationRoute of administration: The route by which the medication is administrated into the body.
For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible.
  • Intramuscular
CommentComment: Additional narrative about the medication statement not captured in other fields.
First administeredFirst administered: The date and time when the medication was first taken by, or administered to, the individual.
Number of doses administeredNumber of doses administered: The total number of doses administered.
For example: 1 stat dose of prophylactic antibiotics; or 10 doses in an antibiotic course over 5 days.
Contacts for tracingContacts for tracing: A generic section header which should be renamed in a template to suit a specific clinical context.
Baby's fatherBaby's father: A generic section header which should be renamed in a template to suit a specific clinical context.
Exposure contact for tracingExposure contact for tracing: An individual who may be the source of infectious disease and at risk of spreading it to others or an individual who may be at risk after exposure to an infected individual.
Data
LabelLabel: Administrative identifier or label to anonymise the contact.
  • Father
Person - fatherPerson - father: An individual human being.
Structured name of a person - fullStructured name of a person - full: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
RelationshipRelationship: The relationship or role of the individual to the subject of the health record.
For example - the copyholder of an advance care record; contact person in an organisation; relative in a family history entry; specimen collector; or witness to a fall or accident. If the individual being described using this archetype is the subject of the health record, then this data element is redundant.
  • Father
Address - localAddress - local: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Address - internationalAddress - international: Details about the location of a person, physical building or landmark.
Address lineAddress line: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
City/TownCity/Town: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
District/CountyDistrict/County: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
State/Territory/ProvinceState/Territory/Province: The name of a major government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'New South Wales' and 'Queensland' in Australia; 'British Columbia' and 'Nova Scotia' in Canada; and the Counties of 'Cornwall', 'Middlesex' & 'Surrey' in Jamaica.
Postal codePostal code: The code for a postal delivery area containing the address, as defined by the relevant postal delivery service.
Also known as a postcode or ZIP code.
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa
  • Andorra
  • Angola
  • Anguilla
  • Antarctica
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Aruba
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas (the)
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda
  • Bhutan
  • Bolivia (Plurinational State of)
  • Bonaire, Sint Eustatius and Saba
  • Bosnia and Herzegovina
  • Botswana
  • Bouvet Island
  • Brazil
  • and MORE
Phone - unspecified number/sPhone - unspecified number/s: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Business use 
  • Personal use 
  • Both business and personal use 
Contacted?Contacted?: Has contact been made with the exposed individual?
  • Yes 
  • No 
  • Unsure 
Symptomatic?Symptomatic?: Is the exposed individual reporting any relevant symptoms or signs?
  • Yes 
  • No 
  • Unsure 
Treated?Treated?: Has the exposed individual been treated?
  • Yes 
  • No 
  • Unsure 
CommentComment: Additional narrative about the contact not captured in other fields.
Laboratory test screeningLaboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Syphilis screeningSyphilis screening: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test nameTest name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Non-treponemal screening test
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date/time sent to laboratoryDate/time sent to laboratory: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Date/time result reportedDate/time result reported: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Specimen collection detailsSpecimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Specimen typeSpecimen type: The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
  • Blood
Date/time received by laboratoryDate/time received by laboratory: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collectedDate/time collected: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
Non-treponemal screening testNon-treponemal screening test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • VDRL
  • TRUST
  • RPR
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Weakly reactive/Borderline
  • Reactive/Positive
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
BPG administrationBPG administration: An assertion about the current use of a single medication by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication nameMedication name: Name of the medication.
It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'.
  • Benzathine benzylpenicillin
Dose and frequencyDose and frequency: Complete narrative description about how the ordered item is to be used.
Route of administrationRoute of administration: The route by which the medication is administrated into the body.
For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible.
  • Intramuscular
CommentComment: Additional narrative about the medication statement not captured in other fields.
First administeredFirst administered: The date and time when the medication was first taken by, or administered to, the individual.
Number of doses administeredNumber of doses administered: The total number of doses administered.
For example: 1 stat dose of prophylactic antibiotics; or 10 doses in an antibiotic course over 5 days.
Medication screeningMedication screening: Series of questions and associated answers used to screen for the use of medications.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific medicationSpecific medication: Details about a specified medication or grouping of medications relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific medications or groupings of medication.
Medication nameMedication name: Name of medication or grouping of medication.
For example: 'alendronic acid', 'anti osteoporosis medications' or 'bisphosphonates'. Coding of the 'Medication name' with a terminology is preferred, where possible.
  • Benzathine benzylpenicillin
GivenGiven: Is there a history of use of a specific medication or group of medications?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. For example an alternative valueset using the DV_TEXT datatype can be: Currently using [The individual currently uses the specific medication either on a regular basis or as required.] Never used [The individual has never used the specific medication.] Used in the past [The individual has used the specific medication in the past, but isn't currently using it.] Unknown [It is not known whether the individual uses or has used the specific medication.]
  • Yes 
  • No 
  • Unknown 
CommentComment: Additional narrative about the specific medication question, not captured in other fields.
Other contactOther contact: A generic section header which should be renamed in a template to suit a specific clinical context.
Exposure contact for tracingExposure contact for tracing: An individual who may be the source of infectious disease and at risk of spreading it to others or an individual who may be at risk after exposure to an infected individual.
Data
LabelLabel: Administrative identifier or label to anonymise the contact.
Person - contact for tracingPerson - contact for tracing: An individual human being.
Structured name of a person - fullStructured name of a person - full: Discrete components of an individual's name.
TitleTitle: One or more honorific form(s) of address commencing a name.
Occurrences for this data element are set to 0..* to allow for more than one Title to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Doctor'; 'Ms'; 'Mx'; or 'Professor Dr'.
  • Codes from National Data Dictionary
First nameFirst name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Middle nameMiddle name: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
NicknameNickname: One or more unique name(s) used to identify an individual within a family group.
Occurrences for this data element are set to 0..* to allow for more than one Given name to be recorded. In addition, this data element may be cloned and renamed within a template to allow discrete recording of different types of Given name - for example 'First name', 'Middle name', 'Preferred name' or 'Nickname', as required for a specific use case.
Last nameLast name: One or more name(s) that an individual has in common with a family group.
Also known as 'Last name' or 'Surname'. Occurrences for this data element are set to 0..* to allow for more than one Family name to be recorded. Complex names such as 'El Haddad' or 'van der Heyden' can be recorded using this naming pattern, as identified in ISO 22220 (Annex F), but for the intended use case for this archetype it is most likely that the full family name will be recorded as a string.
SuffixSuffix: One or more term(s) placed after all other name components, usually to differentiate an individual from a family member with identical Given and Family name components.
Occurrences for this data element are set to 0..* to allow for more than one Suffix to be recorded. Coding with an external terminology is preferred, where possible. For example: 'Junior (Jr)'; 'Senior (Sr)'; 'Second (II)'.
  • Codes from National Data Dictionary
Medical record numberMedical record number: Identifier associated with the individual.
Occurrences for this data element is set to 0..* to allow for more than one Identifier to be recorded. Note that the DV_IDENTIFIER data type contains multiple subcomponents for recording the ID value, type, issuer and assigned. For example - social security number; driver's license; or passport number.
Address - Local + GISAddress - Local + GIS: Details about the location of a person, physical building or landmark.
Street addressStreet address: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
LandmarkLandmark: An unstructured address line representing all relevant street-level or post-box details that would support the identification of a location.
Occurrences for this data element is set to 0..* to allow one or more free text 'Address line' data elements to represent the huge variety of ways that ‘street-level' details may need to be recorded within the context of a specified 'Town'. Multiple address lines can be represented in a template, renamed as 'Address line 1', 'Address line 2,' etc. For example: '7A/52 Davis Street' or 'Apartment 7A' as Address line 1 with '52 Davis Street' as Address line 2; a roadside mail box location, such as 'RMB 725, Princes Highway'; or using a descriptive landmark, such as or 'Corner of Smith & Brown Streets' or 'Second house north of the general store with the red door'.
CommunityCommunity: The name of the lowest level locality that contains the address.
For example: suburb, town, city, settlement, village, or community. Coding with an external terminology is preferred, where possible. For example: 'Fitzroy'; 'Manchester'; 'Kingston' or 'Bergen'.
  • Aenon Town
  • Alley
  • Alston
  • Ashley
  • Banks
  • Beckford Kraal
  • Brandon Hill
  • Brixton Hill
  • Bucknor
  • Bucks Common
  • Bushy Park
  • Chapelton
  • Chateau
  • Cockpit
  • Coffee Piece
  • Colonels Ridge
  • Coxswain
  • Crofts Hill
  • Crooked River
  • Cumberland
  • Curatoe Hill
  • Dawkins
  • Effortville
  • Four Paths
  • Frankfield
  • Freetown
  • Gimme-me-bit
  • Glenmuir
  • Grantham
  • Gravel Hill
  • Hayes
  • and MORE
ParishParish: The name of a local government district or geographical area that contains the address.
Coding with an external terminology is preferred, where possible. For example: 'Surf Coast' and 'Yarra' local government councils in Victoria, Australia;and the Parishes of 'Saint Andrew' and 'Kingston' in Jamaica..
  • Clarendon
  • Hanover
  • Kingston
  • Manchester
  • Portland
  • Saint Andrew
  • Saint Ann
  • Saint Catherine
  • Saint Elizabeth
  • Saint James
  • Saint Mary
  • Saint Thomas
  • Trelawny
  • Westmoreland
CountryCountry: The name of the country containing the address.
For example: Australia; Canada; Jamaica; or Norway. Coding with an external terminology, such as EN ISO 3166–1 Alpha 2 country code, is recommended.
  • Jamaica
Geolocation codeGeolocation code: Unique identifier that represents a precise geographical location.
Also known as a geocode. For example: GPS coordinates concatenating longitude, latitude +/-altitude; Open Location Code or Plus Code; Universal Transverse Mercator (UTM); and geohash.
LatitudeLatitude: Horizontal (y) coordinate of a geolocation for the address.
Latitude is represented by positive values north of the equator and negative values south of the equator. For example the latitude of the Eiffel Tower is 48.858093.
-90..90 °
LongitudeLongitude: Horizontal (x) coordinate of a geolocation for the address.
Longitude is represented by negative values west of Prime Meridian and positive values east of Prime Meridian. For example the longitude of the Eiffel Tower is 2.294694.
-180..180 °
Map URLMap URL: Link to a location on an online map.
For example: a location on a Google or iOS map.
Phone - personal mobilePhone - personal mobile: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Personal use 
Phone - home landlinePhone - home landline: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Personal use 
Phone - work numberPhone - work number: Details about a specified type of electronic communication.
TypeType: The type or form of electronic communication.
The DV_CODED_TEXT value set supports recording of the most common electronic communications used in health. If other alternatives are required the DV_TEXT data type can be used to record other types of electronic communication such as social media or video conferencing URLs within a template.
  • Mobile (cellular) telephone 
  • Telephone (excluding mobile telephone) 
ValueValue: The unique combination of alphanumeric characters, relevant for representation of 'Type'.
For example: area code + landline phone/pager number; country code + mobile phone number; or email address.
PurposePurpose: The purpose or use for the identified type of electronic communication.
  • Business use 
Contacted?Contacted?: Has contact been made with the exposed individual?
  • Yes 
  • No 
  • Unsure 
Symptomatic?Symptomatic?: Is the exposed individual reporting any relevant symptoms or signs?
  • Yes 
  • No 
  • Unsure 
Treated?Treated?: Has the exposed individual been treated?
  • Yes 
  • No 
  • Unsure 
CommentComment: Additional narrative about the contact not captured in other fields.
Laboratory test screeningLaboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Syphilis screeningSyphilis screening: Details about a specified investigation or grouping of investigations relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations.
Test nameTest name: Name of the diagnostic investigation or grouping of investigations.
For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible.
  • Non-treponemal screening test
Done?Done?: Is there a history of the investigation being carried out?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
  • Yes 
  • No 
  • Unknown 
Date/time sent to laboratoryDate/time sent to laboratory: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
Date/time result reportedDate/time result reported: Indication of timing related to the investigation.
The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year.
ConclusionConclusion: Brief description, summary or interpretation of the investigation outcome.
For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings. In that situation, nest an appropriate CLUSTER archetype within the following 'Additional details' SLOT.
Specimen collection detailsSpecimen collection details: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Specimen typeSpecimen type: The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
  • Blood
Date/time received by laboratoryDate/time received by laboratory: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]
Date/time collectedDate/time collected: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
CommentComment: Additional narrative about the specimen not captured in other fields.
Optional[{fhir_mapping=Specimen.note}]
CommentComment: Additional narrative about the diagnostic investigation test not captured in other fields.
Non-treponemal screening testNon-treponemal screening test: The result of a laboratory test designed to detect and quantify the presence of specific antibodies produced by the immune system in response to a microorganism, tissue, allergen, or physiological process, within a clinical specimen.
Test nameTest name: Name of the antibody test.
Coding with an external terminology is recommended, if available. For example: SARS-CoV-2 IgG antibody test.
  • VDRL
  • TRUST
  • RPR
PresencePresence: Statement about detection of the identified antibody in the specimen.
  • Non-reactive/Negative
  • Weakly reactive/Borderline
  • Reactive/Positive
Quantitative resultQuantitative result: Quantitative assessment of the amount of the identified antibody in the specimen.
  • Ratio
CommentComment: Additional narrative about the test finding not captured in other fields.
Medication administeredMedication administered: An assertion about the current use of a single medication by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication nameMedication name: Name of the medication.
It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'.
Route of administrationRoute of administration: The route by which the medication is administrated into the body.
For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible.
  • Intramuscular
CommentComment: Additional narrative about the medication statement not captured in other fields.
First administeredFirst administered: The date and time when the medication was first taken by, or administered to, the individual.
Number of doses administeredNumber of doses administered: The total number of doses administered.
For example: 1 stat dose of prophylactic antibiotics; or 10 doses in an antibiotic course over 5 days.
Medication screeningMedication screening: Series of questions and associated answers used to screen for the use of medications.
The answers may be self-reported.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Specific medicationSpecific medication: Details about a specified medication or grouping of medications relevant for the screening purpose.
Use separate instances of this CLUSTER to differentiate between specific medications or groupings of medication.
Medication nameMedication name: Name of medication or grouping of medication.
For example: 'alendronic acid', 'anti osteoporosis medications' or 'bisphosphonates'. Coding of the 'Medication name' with a terminology is preferred, where possible.
  • Benzathine benzylpenicillin
GivenGiven: Is there a history of use of a specific medication or group of medications?
In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case. For example an alternative valueset using the DV_TEXT datatype can be: Currently using [The individual currently uses the specific medication either on a regular basis or as required.] Never used [The individual has never used the specific medication.] Used in the past [The individual has used the specific medication in the past, but isn't currently using it.] Unknown [It is not known whether the individual uses or has used the specific medication.]
  • Yes 
  • No 
  • Unknown 
CommentComment: Additional narrative about the specific medication question, not captured in other fields.
BPG administrationBPG administration: An assertion about the current use of a single medication by an individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Medication nameMedication name: Name of the medication.
It is strongly recommended that the 'Medication name' be coded with a terminology capable of triggering decision support, where possible. Free text entry should only be used if there is no appropriate terminology available or for customised extemporaneous preparations. The extent of coding may vary from the simple generic or product name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. For example: 'Plaquenil'; 'Ibrutinib 420 mg tablet'; 'Rectinol ointment, 50 g, tube'; or 'Hydrofibre dressing with silver'.
  • Benzathine benzylpenicillin
Dose and frequencyDose and frequency: Complete narrative description about how the ordered item is to be used.
Route of administrationRoute of administration: The route by which the medication is administrated into the body.
For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible.
  • Intramuscular
CommentComment: Additional narrative about the medication statement not captured in other fields.
First administeredFirst administered: The date and time when the medication was first taken by, or administered to, the individual.
Number of doses administeredNumber of doses administered: The total number of doses administered.
For example: 1 stat dose of prophylactic antibiotics; or 10 doses in an antibiotic course over 5 days.
Additional notesAdditional notes: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Additional notesAdditional notes: The summary, assessment, conclusions or evaluation of the clinical findings.
Field investigator classificationField investigator classification: A generic section header which should be renamed in a template to suit a specific clinical context.
Field diagnosisField diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Diagnosis nameDiagnosis name: Identification of the problem or diagnosis, by name.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Cause of deathCause of death: Details about specific diseases, conditions or injuries that caused or contributed to the death of an individual.
Data
Immediate causeImmediate cause: The disease, condition or injury that directly led to, or occurred closest to, the time of death.
It is recommended that 'Direct cause' be coded with an external terminology. This data element may also be considered as the Cause labelled as 'A' within a death certificate recording a sequence of events leading to death. For example: Cerebral haemorrhage (as 'Direct cause', A) - 'due to' Metastasis of the brain ('Antecedent cause B'); - 'due to' Breast cancer (as the earliest 'Antecedent cause C'; or 'Underlying cause').
Intermediate cause(s)Intermediate cause(s): Details about one or more diseases, conditions or injuries in the sequence of events preceding death, recorded in order from most recent onset to the earliest onset.
In the following example, there would only need to be two instances of this 'Antecedent cause(s)' CLUSTER represented in a template: - Cerebral haemorrhage (as 'Direct cause', A) - 'due to' Metastasis of the brain ('Antecedent cause B'); - 'due to' Breast cancer (as the earliest 'Antecedent cause C'; or 'Underlying cause'). If there is more than one 'Antecedent cause', each is represented as a separate instance of this CLUSTER.
Intermediate causeIntermediate cause: Identification of an antecedent disease, condition or injury that directly contributed to the 'Direct cause'.
It is recommended that 'Cause' be coded with an external terminology.
Underlying causeUnderlying cause: Details about one or more diseases, conditions or injuries in the sequence of events preceding death, recorded in order from most recent onset to the earliest onset.
In the following example, there would only need to be two instances of this 'Antecedent cause(s)' CLUSTER represented in a template: - Cerebral haemorrhage (as 'Direct cause', A) - 'due to' Metastasis of the brain ('Antecedent cause B'); - 'due to' Breast cancer (as the earliest 'Antecedent cause C'; or 'Underlying cause'). If there is more than one 'Antecedent cause', each is represented as a separate instance of this CLUSTER.
Underlying causeUnderlying cause: Identification of an antecedent disease, condition or injury that directly contributed to the 'Direct cause'.
It is recommended that 'Cause' be coded with an external terminology.
Other significant conditionsOther significant conditions: Details about other significant conditions that may have contributed to the death, but without a causal association.
ConditionCondition: Name of a significant condition that may have contributed to the death, but without a causal association.
It is recommended that 'Condition' be coded with an external terminology.
Field classificationField classification: Classification for an identified infectious disease as part of a disease surveillance investigation.
Data
Index diseaseIndex disease: The name of the infectious disease under investigation.
This data element may be redundant if the index disease has been identified elsewhere within a template.
  • Congenital syphilis
Final classificationFinal classification: Classification of the likelihood of the 'Index disease' as causal after completion of a case investigation.
Not to be used to record the 'Initial classification' at the initiation of a case investigation.
  • Pending 
  • Probable 
  • Laboratory confirmed 
  • Clinically confirmed 
  • Discarded 
  • Inconclusive 
Reason for classificationReason for classification: The broad category of the reason for the classification.
For example: lost to follow-up, child of an infected mother.
Epidemiological linkEpidemiological link: Identification of the cause or source of transmission.
  • Human to human transmission 
Aetiology categoryAetiology category: The category for the cause of infection.
For example: imported, import-related, endemic, vaccine-associated, congenital or unknown.
  • Congenital case 
  • Unknown 
Contribution to deathContribution to death: Assessment of the relationship between the index disease and the death of the individual.
  • Related 
  • Unrelated 
  • Unknown 
CommentComment: Additional narrative about the classification, not captured in other fields.
Final classificationFinal classification: A generic section header which should be renamed in a template to suit a specific clinical context.
DiagnosisDiagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.
Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Diagnosis nameDiagnosis name: Identification of the problem or diagnosis, by name.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
ClassificationClassification: Classification for an identified infectious disease as part of a disease surveillance investigation.
Data
Index diseaseIndex disease: The name of the infectious disease under investigation.
This data element may be redundant if the index disease has been identified elsewhere within a template.
  • Congenital syphilis
Final classificationFinal classification: Classification of the likelihood of the 'Index disease' as causal after completion of a case investigation.
Not to be used to record the 'Initial classification' at the initiation of a case investigation.
  • Pending 
  • Probable 
  • Laboratory confirmed 
  • Clinically confirmed 
  • Discarded 
  • Inconclusive 
Reason for classificationReason for classification: The broad category of the reason for the classification.
For example: lost to follow-up, child of an infected mother.
Epidemiological linkEpidemiological link: Identification of the cause or source of transmission.
  • Human to human transmission 
Aetiology categoryAetiology category: The category for the cause of infection.
For example: imported, import-related, endemic, vaccine-associated, congenital or unknown.
  • Congenital case 
  • Unknown 
Contribution to deathContribution to death: Assessment of the relationship between the index disease and the death of the individual.
  • Related 
  • Unrelated 
  • Unknown 
CommentComment: Additional narrative about the classification, not captured in other fields.