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  4. health record

Definition

data repository regarding the health and healthcare of a subject of care

 

This is an abstract item and should be implemented through one of the concrete specialisations

Term: health record; 
Plural: health records; 

Notes

NOTE 1 The term electronic health record may be used for a health record where all information is stored on electronic media. However, this concept is not formally defined in this International Standard.

NOTE 2 A health record may include, for example, medical records, dental records, social care records.

Examples

Diagrammatic representation

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0..* 1..* is stored on ► 1..* 1..* ◄ maintains 1..* 0..* is documented in ► 0..* 0..* ◄ is recorded in 0..* 0..* is recorded in ► 1..* 0..* implies access to ► 0..* 0..* is recorded in ► 0..* 0..* ◄ is recorded in 0..* 1..* ► 0..* 1 ◄ is extracted from 0..* 1..* ◄ is accessed during 0..* 1..* ◄ is accessed during 1..* 1 concerns ► 1..* 0..* is recorded in ► medium (duplicate): material on which data is stored (e.g., a magnetic disk) medium (duplicate) care plan: dynamic, personalized plan including identified needed healthcare activities, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process care plan subject of care desire: desire expressed by the subject of care or the subject of care proxy regarding the performance of certain healthcare activities subject of care desire healthcare process: set of interrelated or interacting healthcare activities which transforms inputs into outputs healthcare process healthcare documenting: healthcare activity element where health records are created or maintained healthcare documenting data repository: an identifiable data storage facility data repository health record extract: part or all of a health record extracted for the purpose of communication health record extract professional health record: health record held under the responsibility of one healthcare provider and maintained by one or several healthcare professionals professional health record healthcare mandate: mandate (commission) based on a commitment and either an informed consent or an authorization by law, defining the rights and obligations of one healthcare actor with regard to his involvement in healthcare processes performed for a specific subject of care healthcare mandate healthcare activity period: time interval during which healthcare activities are performed for a subject of care healthcare activity period health record: data repository regarding the health and healthcare of a subject of care health record personal health record: health record held and maintained by the subject of care or a subject of care proxy personal health record non-ratified healthcare information: healthcare information the relevance of which has not been assessed and explicitly stated as valid by a healthcare professional non-ratified healthcare information healthcare activity: activity intended directly or indirectly to improve or maintain a health state healthcare activity health record component: part of a health record that is identifiable for the purposes of referencing and revision health record component subject of care: healthcare actor with a person role; who seeks to receive, is receiving, or has received healthcare subject of care
health record

Simple graph - health record
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Required associations

one or more healthcare activities is recorded in a number of health records
one or more healthcare documentings maintains one or more health records
one or more healthcare processes is documented in a number of health records
one or more healthcare mandates implies access to a number of health records
a number of health records one or more health record components
a number of health records is accessed during one or more healthcare activities
a number of health records is accessed during one or more healthcare activity periods
one or more health records concerns exactly one subject of care
a number of health records is stored on one or more media

Optional associations

a number of care plans is recorded in a number of health records
a number of healthcare mandates is recorded in a number of health records
a number of subject of care desires is recorded in a number of health records
a number of non-ratified healthcare informations is recorded in a number of health records
a number of health record extracts is extracted from exactly one health record

Generalisations

    data repository
health record

Specialisations

health record
    electronic health record
    personal health record
    personal health record
    professional health record
    professional health record