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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

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.

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.

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

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.

primaryInformationRecipient: the party 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

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

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

pertinentInformation3: links the Care Provision Event to a set of pertinent clinical statements provided as part of the information supplied in the Care Record. Refer to A_CareStatement in the Care Structures topic for further description this local CMET.

reason: a relationship to a concern recorded as the primary 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. Refer to A_ConcernTracking in the Care Structures topic for further description this local CMET.

pertinentInformation2: a Care Record has a set of lists containing various Clinical Statements as relevant information, which is ongoing and 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. Refer to A_StatementCollector in the Care Structures topic for further description this local CMET.

Reference: the Care Event or Care Events (encounter-based, episode-based, or general care-based collections) that the Care Record relates to, represented by the A_CareEvent CMET

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.