Transaction: Epidemiological study

General information

STATUS:

Published

OWNER:

eHealth Platform

STANDARD:

KMEHR

VERSION:

1.0

DATE:

2002-10-15

DEFINITION:

This transaction is used to transfer epidemiological data.

Guidelines

Generalities

This transaction must, at least, be compliant with the KMEHR level 1. Other levels can be used at the discretion of the user.

Transaction elements

id	id of the transaction according to theID-KMEHR convention.
cd	You must use the value 'epidemiology' from CD-TRANSACTION. You can always add your own local codes.
date	This is the date of reporting.
time	This is the time of reporting.
author	This is the the person assuming the responsibility of the medical content of the letter. It can be specified by a combination of hcparty. There must be at least one hcparty identifying a person.
iscomplete	If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later.
isvalidated	If this is false, this means that the information has not been validated medically.

Structure overview

You have the choice between:

text(s) : to transfer your epidemiologica report as free text,
lnk(s) : to encapsulate your epidemiological report as a multimedia object (Word document for example),
heading(s) and/or item(s) : to further structure your epidemiological report.

Headings

We recommend the use of the following headings from CD-HEADING

history	Patient's history (antecedents)
clinical	Clinical investigation (including patient's complaints)
technical	Technical investigation
assessment	Current diagnoses and hypotheses
clinicalplan	Clinical plan of action
technicalplan	Technical plan of action
treatment	Proposed treatment

Each heading can contain:

text(s) : to transfer your paragraph as free text,
lnk(s) : to encapsulate your paragraph as a multimedia object (Word document for example),
item(s): to further structure your paragraph.

Items

Most items of CD-ITEM are useful. A few items are more specific for the epidemiological report.

Item type (cd)	Item purpose	Item structure
encounternumber	your local admission number	Any national standard dictionary could be used to code the content of the items but at this stage of the specification, we recommend to transfer the content of the items as free text.
encountertype	hospitalisation, emergency, etc ...
encounterdatetime	admission date and time
encounterlocation	to document institution, site, unit, room and bed
encounterresponsible	responsible of the encounter (can be used to identify the individual and/or the medical department in charge of the patient)
transactionreason	reason for admission
encounterorigin	origin of the patient before admission (ambulance, home, ...)
referrer	the type of entity that referred the patient to the organisation
admissiontype	type of admission process: (planned admission, emergency, ...)
healthissue	to specify current problem(s), diagnoses, hypotheses but also antecedents.
allergy	allergy
adr	adverse drug reaction
vaccine	vaccine administration
medication	pharmaceutical treatment
treatment	treatment other than pharmaceutical
habits	usage of alcohol, tobacco, drug, ...
complaint	patient's complaint
clinical	results of clinical investigations
technical	results of technical investigations
risk factor	like communicable disease, work hazard, ...
socialrisk	like unemployed, junky, ...

Any national standard dictionary could be used to code the content of the items but at this stage of the specification, we recommend to transfer the content of the items as free text.