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Care Record Topic

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Patient Care Normative Ballot Content

Description Parent: Care Provision (REPC_DM000000UV)

Care Record RMIM Overview

The Care Record RMIM captures the data and associations that are needed when the responsibility of Care Provision has been assumed and a record summary of the acts relevant to the care provision including any requested, proposed or activated care plans. This model, and its accompanying diagram, is very similar to the Care Provision DMIM but uses "local CMETs" to abstract the complexity of the care structures associated with the Care Provision Request Act.

The reader should refer to the DMIM discussion before reviewing the RMIM followed by the discussion for each care structure. The discussion of this model will focus on features that do not exist in the DMIM, and were not directly addressed in the review of that model.

CareProvisionEvent Focal Class

A Care Provision Event records and summarizes the acts relevant whilst the performer is responsible for the care provision of the target of care.

Associations

The following associations are defined for a Care Record. Each association captures the relationship between the Care Provision Event and an entity or act that plays a significant part of the Care Record.

Participations

The first is that the care provision points to the SubjectChoice. In the choicebox the following relations are presented:

recordTarget: the record target is the entity for which the Care Record is being recorded. There can only be one record target for a Care Record. The target entity information is captured within the R_Patient CMET or R_CaredEntity local CMET. Refer to the respective CMETs for further description.

subject: the subject or subjects are the target(s) of the care provision being record when the subject is not the record target. The subject information is captured within the R_Patient CMET or R_CaredEntity local CMET. Refer to the respective CMETs for further description.

location: to indicate a set of locations where care was provided for this care record.

dataEnterer: the transcriptionist who enters the information of the Care Record. The data enterer information is captured within the R_AssignedPerson CMET.

author: the party that produces the record of a Care Provision Event. This may be an assigned person or organization (R_AssignedParty) such as a healthcare provider, a related party (R_RelatedParty) such as a family member or a non-healthcare organization, or the patient (R_Patient) themselves. Refer to the respective CMETs for further description.

participant: for anyone else involved in Care Provision and or contributing to the Care Record. It is expected that implementations constrain this to the specific set of participations needed.

verifier the supervisor who verifies the Care Record. There is support for more than one level of verification. The verifying party information is captured within the R_AssignedPerson CMET.

performer: the parties who take part in actually carrying out the Care Provision Event being record. There may be multiple performers because several parties may collaborate in performance of Care Provision. These parties may be an assigned person or organization (R_AssignedParty) such as a healthcare provider, a related party (R_RelatedParty) such as a family member or a non-healthcare organization, or the patient (R_Patient) themselves. Refer to the respective CMETs for further description.

InformationRecipient: the parties who is intended to receive the Care Record notification. The recipient is usually the author of the associated care transfer request or the primary care provider. These may be represented by an assigned person or organization (R_AssignedParty), a related party (R_RelatedParty) such as a family member or court, or the patient (R_Patient) themselves. Refer to the respective CMETs for further description.


Act Relationships


pertinentInformation2: links the Care Provision Event to a set of pertinent clinical statements provided as part of the information supplied in the Care Record.

component1: links the Care Provision Event to the set of clinical statements that are part of the Care Provision.

reason: a relationship to recorded Clinical Statement as the reason for the Care Provision. A problem, not specifically a diagnosis, which is the primary reason for the Care Provision can also be presented using this relationship.

component3: a Care Record connects to the StatementCollectorActList which has a set of lists containing various Clinical Statements as relevant information, which are subjects of the list. A list is dynamic with ongoing additions and is not necessarily captured as part of the Care Provision Event. It may include a problem list, current medication list or a list of risk factors.

component: the relationship between the set of clinical statements and the list in which they are categorized.

inFullfilmentOf: this relationship links the Care Provision Event to the promise and/or request Acts that it fulfills. Only the id attribute is provided to link the Act for which the Care Provision Event fulfills.

component2: links the Care Provision Event to the care plan which is carried out as part of the Care Provision. Refer to Care Plan Topic for further description of this local CMET.

pertinentInformation1: links the Care Provision Event to the care plan which is informative in the context of the care provision but not directly relevant to this Care Record. Refer to Care Plan Topic for further description this local CMET.

authorization: This allows a patient to consent to the Care Record, information exchange, care plan and so on.

Reference: a set of other Care Records that contain relevant information for this Care Record.

ReplacementOf: a link to a replaced Care Record. The Care Provision Event being the target of this act relationship has a status of obsolete and can either contain just the instance identifier of the replaced Care Record or the entire Care Record information.

subjectOf: this links the care record to the list of documented changes in the record.