Care Record

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Introduction

This represents a substantial update to the Care Record Topic.

All information about a patient recorded by a health care provider is done so via entry of a Care Record. To be precise, it is part of an ActClass COMPOSITION: A context representing a grouped commitment of information to the EHR. It is considered the unit of modification of the record, the unit of transmission in record extracts, and the unit of attestation by authorizing clinicians. A composition represents part of a patient record originating from a single interaction between an authenticator and the record. Unless otherwise stated all statements within a composition have the same authenticator, apply to the same patient and were recorded in a single session of use of a single application. A composition contains organizers and entries.

This is an effort to define the complete representation of a Care Record composition, including how, when, why, and where relationships to Health Concerns and Care Plans are represented. In addition, it will contain the detailed specification for Clinical Context needed for multiple uses to properly (accurately, safely, and otherwise clinically relevant) interpret any clinical informaiton.

Project Scope

A new project is required to update this topic.