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 A

ACCESS_POLICY

adverse event

unintended event that has negative influence upon healthcare processes

adverse event management

set of healthcare activities performed in response to an adverse event

appointment

arrangement to meet someone at a particular time and place

attachment value

data value used for representing information objects that may require special processing operations to be performed in order for the data to be interpreted or rendered

attestation information

base component documenting the details of an attestation of a set of electronic health record components

audit information

documentation of the details of a revision of a base component

AUDIT_INFO

authorization by law

provision in legislation that in certain circumstances may overrule the need for informed consent

automated healthcare

method of delivering healthcare initiated by a responsible healthcare actor and thereafter delivered automatically by an automatic medical device

automatic medical device

medical device capable of performing automated healthcare activities

 B

base component

abstract class that include the properties common for all revisable classes included in EHR extract

boolean value

data value used for representing the values of two-valued logic

 C

care commitment
see healthcare commitment
care employment
see healthcare employment
care funds
see healthcare funds
care guideline
see clinical guideline
care mandate
see care period mandate
care map
see clinical pathway
care matter
see healthcare matter
care need
see needed healthcare activity
care organization
see healthcare organization
care pathway
see clinical pathway
care period mandate

healthcare mandate commissioning a mandated period of care

care personnel
see healthcare personnel
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
see uniprofessional care plan
care planning
see healthcare planning
care process
see healthcare process
care professional
see healthcare professional
care professional entitlement
see healthcare professional entitlement
care provider
see healthcare provider
care supporting organization
see healthcare supporting organization
care third party
see healthcare third party
certificate related to a healthcare matter

official document issued by a healthcare actor attesting healthcare matters relating to a subject of care

client
see subject of care
clinical governance
see healthcare quality management
clinical guideline

set of systematically developed statements to assist the decisions made by healthcare actors about healthcare activities to be performed with regard to specified health issues

clinical pathway

pathway for the healthcare activities informing the content of core care plans

clinical process

healthcare process encompassing all healthcare provider activities and other prescribed healthcare activities that addresses identified or specified health issues

clinical process episode

health related period that includes all healthcare activity periods in one clinical process

clinical process interest

health thread comprising all healthcare matters related to a specific clinical process

clinical process mandate

clinical process outcome evaluation

healthcare evaluation where the effects of a clinical process on a health state are assessed against the target condition and/or a health condition representing the input health state

clinical report

health record extract conveying specifically focused healthcare information in order to fulfil current information needs of the recipient

cluster

structure component used for creating hierarchical structures within an entry and with elements as leaf nodes

coded simple value

data value used for representing a code in a code system implied and fixed by the context in which this data value occurs

coded value

data value used for representing a code in a referenced code system

commission to export personal information
see mandate to export personal information
commissioned period of care
see mandated period of care
commitment

action resulting in an obligation by one or more of the participants in the act to comply with a rule or perform a contract

composition

structure component containing information composed during one clinical encounter or documentation session, and committed within one EHR

concept

unit of knowledge created by a unique combination of characteristics

concept system
see system of concepts
consent competence

capability of the subject of care and/or the subject of care proxy to give informed consent or dissent

considered condition

potential health condition considered by a healthcare actor on the basis of one or more observed conditions

considered health condition
see considered condition
contact

interaction between a subject of care and one or more healthcare personnel

contact
see healthcare activity period
contact element
see healthcare activity period element
contact period

healthcare activity period during which a contact occurs

content

abstract structure component that holds all properties common for sections and entries

continuity facilitator commission
see continuity facilitator mandate
continuity facilitator mandate

healthcare mandate assigning the right and obligation to monitor and coordinate the delivery of care described in those care period mandates related to healthcare matters linked by specific health threads

continuity of care

efficient, effective, ethical care delivered through interaction, integration, co-ordination and sharing of information (3.9.5) between different healthcare actors over time

core care plan

reusable content and structure for a potential care plan for a specified set of circumstances

cumulative episode of care
see episodes of care bundle
CV

 D

data

reinterpretable representation of information (3.9.5) in a formalized manner suitable for communication, interpretation or processing

data repository

an identifiable data storage facility

data value

data contained in an element

date time value

data value used for representing a precise point in time with a resolution of second and optionally fraction of second

date value

data value used for representing a point in time with a resolution of day of month

demand commission
see demand mandate
demand for care

demand for healthcare provider activities expressed by a healthcare actor

demand for healthcare
see demand for care
demand for initial contact

first demand for care concerning one or more specific health issues to be assessed by a healthcare provider

demand mandate

healthcare mandate implying the right and obligation to demand healthcare activities

demographic cluster

structure component used for creating hierarchical structures within an demographic entry and with demographic elements as leaf nodes

demographic element

record component within a demographic entity or demographic cluster containing a single data value

demographic entity

structure component containing demographic information describing a single person, device, software agent or organisation

demographic extract

demographic information extracted for the purpose of being included in an EHR extract

demographic folder

structure component used for creating hierarchical structures within a demographic extract and with demographic entities as leaf nodes

demographic item

abstract structure component that holds all properties common for demographic clusters and demographic elements

deprecated term

term rejected by an authoritative body

discharge report

clinical report concerning a completed, mandated period of care

discharge summary

discharge report summarizing a mandated period of care

discounted condition
see excluded condition
dissent

refusal to permit specific healthcare activities to be performed

duration value

data value used for representing a lapse of time

 E

EHR extract
see electronic health record extract
electronic health record

repository of information (3.9.5) regarding the health of a subject of care in computer processable format

electronic health record

electronic health record component

health record component which only includes information in electronic format

electronic health record component

electronic health record extract

health record extract consisting solely of electronic record components

electronic patient summary

electronic health record extract containing essential healthcare information intended for specific uses

electronic record component
see electronic health record component
element

electronic health record component within an entry or cluster containing a single data value

encounter
see contact period
entry

structure component that represents the data documenting one clinical observation or a series of related observations, or a clinical statement, an explanation of clinical reasoning, a healthcare intention, plan or action.

episode of care

health related period during which healthcare activities are performed to address one health issue as identified by one healthcare professional[

episode of healthcare
see episode of care
episodes of care bundle

group of episodes of care delineated by a health thread

episodes of healthcare bundle
see episodes of care bundle
excluded condition

considered condition that one or more healthcare professionals have determined not to be consistent with the known observed conditions

external link

base component that describes an association from information in an EHR extract to information outside that EHR extract

extracted component set

structure component extracted from an EHR for the purpose of being communicated in an EHR extract as the target of one or more links

 F

folder

structure component used for creating hierarchical structures within an EHR extract and with compositions as leaf nodes

 G

goal-addressing episode of care
see health approach

 H

health

health approach

episode of care during which the healthcare activities performed address one specific healthcare goal

health concern

health record extract that includes all health record components associated with a health thread for a specific concern

health condition

observed or potential observable aspects of the health state at a given time

health condition delay

healthcare activity delay caused by a health condition

health condition evolution

health thread showing the evolution of health conditions during a healthcare process, starting with the health condition that represents the input health state

health condition period

health related period during which a health condition has been observed

health issue

representation of an issue related to the health of a subject of care as identified by one or more healthcare actors

health issue related episode
see episode of care
health need

deficit in the current health state compared to aspects of a desired future health state

health objective

desired ultimate achievement of a healthcare process addressing health needs

health problem

health condition considered by a healthcare actor to be a problem

health problem list

health thread linking a set of health problems

health professional
see healthcare professional
health provider
see healthcare provider
health record

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

health record component

part of a health record that is identifiable for the purposes of referencing and revision

health record extract

part or all of a health record extracted for the purpose of communication

health related period

time interval related to the health of a subject of care and/or the provision of healthcare for that subject of care

health self-care activity
see self-care activity
health service provider
see healthcare provider
health state

physical and mental functions, body structure, personal factors, activity, participation and environmental aspects as the composite health of a subject of care

health thread

defined association between healthcare matters as determined by one or more healthcare actors

healthcare

care activities, services, management or supplies related to the health of an individual

healthcare activities bundle

set of healthcare activities

healthcare activity

activity intended directly or indirectly to improve or maintain a health state

healthcare activity commission
see healthcare activity mandate
healthcare activity delay

health related period during which a healthcare activity is planned but not started

healthcare activity directory

directory of the healthcare activities offered by a healthcare provider

healthcare activity element

element of healthcare activity that addresses one type of purpose

healthcare activity management

healthcare activity element during which the status of healthcare activities in a care plan are changed

healthcare activity mandate

healthcare mandate assigning the right and obligation to perform specific healthcare activities

healthcare activity period

time interval during which healthcare activities are performed for a subject of care

healthcare activity period element

part of a healthcare activity period during which one health issue is specifically addressed

healthcare actor

organization or person participating in healthcare

healthcare administration

administrative activities related to healthcare processes

healthcare appointment

appointment for a contact

healthcare approach
see health approach
healthcare assessment

healthcare activity element where an opinion related to health conditions and/or healthcare activities is formed

healthcare commission
see healthcare mandate
healthcare commitment

acceptance of a healthcare mandate by the healthcare actor to whom it is assigned

healthcare communication

healthcare activity element where at least two healthcare actors communicate

healthcare contact
see contact
healthcare contributing activity
see healthcare third party activity
healthcare data

data (3.9.1) produced during healthcare activities

healthcare delivery organization
see healthcare organization
healthcare documenting

healthcare activity element where health records are created or maintained

healthcare employment

contractual framework between a healthcare personnel and a healthcare organization describing the roles and responsibilities assigned to that healthcare personnel

healthcare evaluation

healthcare activity element where aspects of at least one other healthcare activity element is evaluated

healthcare funds

resource provided for funding healthcare delivery

healthcare goal

desired achievement of one or more healthcare activities, considered as an intermediate operational step to reach a specific health objective

healthcare information

information about a person, relevant to his or her healthcare

healthcare information for import

healthcare information that is a candidate for import into a professional health record after a healthcare professional has confirmed its clinical relevance to that professional health record

healthcare information request

request sent out by a healthcare actor to another healthcare actor for specific healthcare information needed for the provision of healthcare to a subject of care

healthcare investigation

healthcare activity element with the intention to clarify one or more health conditions of a subject of care

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 matter

representation of a matter related to the health of a subject of care and/or the provision of healthcare to that subject of care, as identified by one or more healthcare actors

healthcare need
see needed healthcare activity
healthcare needs assessment

healthcare assessment during which a healthcare professional considers a subject of care’s health need and determines the needed healthcare activities

healthcare organization

healthcare provider having an organization role

healthcare party
see healthcare actor
healthcare period mandate
see care period mandate
healthcare personnel

individual healthcare actor having a person role in a healthcare organization

healthcare plan
see care plan
healthcare planning

element of healthcare activity management where a care plan is created or modified

healthcare problem list
see health problem list
healthcare process

set of interrelated or interacting healthcare activities which transforms inputs into outputs

healthcare process evaluation

healthcare evaluation where healthcare processes are systematically assessed against requirements

healthcare professional

healthcare personnel having a healthcare professional entitlement recognized in a given jurisdiction

healthcare professional entitlement

registered authorization given to a person in order to allow the person to have or perform specific roles in healthcare

healthcare provider

healthcare actor that is able to be assigned one or more care period mandates

healthcare provider activity

healthcare activity performed by a healthcare provider

healthcare provider activity request
see request
healthcare quality management

coordinated activities to direct and control a healthcare organization with regard to quality

healthcare resource

resource needed to perform healthcare activities

healthcare resource management

activities to direct and control the supply and use of the healthcare resources required to perform healthcare activities

healthcare service

service that is the result of a healthcare process

healthcare service directory

directory of the types of healthcare services offered by one or more healthcare providers

healthcare service provider
see healthcare provider
healthcare supporting organization

healthcare third party having organizational role

healthcare third party

healthcare actor other than a healthcare provider or the subject of care

healthcare third party activity

healthcare activity performed by a healthcare third party

healthcare treatment

healthcare activity element intended to directly improve or maintain a health state

 I

IDENTIFIED_ENTITY

indirect healthcare activity period

healthcare activity period without the involvement of the subject of care

individual provider
see healthcare personnel
informal carer
see other carer
information

knowledge concerning objects that within a certain context has a particular meaning

information model

formal model of a bounded set of facts, concepts or instructions to meet a specified requirement

informed consent

permission to perform healthcare activities, voluntarily given by a subject of care having consent competence, or by a subject of care proxy, after having been informed about the purpose and the possible results of the healthcare activities

initial contact

contact during which a clinical process is initiated

input health state

health state at the initiation of healthcare process

instance identifier value

data value used for representing identifier that uniquely identifies an object

integer value

data value used for representing an exact integral values.

intended outcome
see target condition
intended outcome
see health objective
item

abstract structure component that holds all properties common for clusters and elements

 K

knowledge

cognizance which is based on reasoning and passes verification

 L

link

base component that describes an association from information in an EHR extract to other information within that EHR extract

 M

mandate to export personal information

healthcare mandate implying the right to communicate health record extracts

mandated period of care

set of healthcare activity periods where a healthcare provider is mandated to perform the healthcare activities required to address specific health needs

medical device

any instrument, apparatus, implement, machine, appliance, implant, in vitro reagent or calibrator, software, material or other similar or related article, intended by the manufacturer to be used, alone or in combination, for human beings for one or more of the specific purpose(s) of

medicinal product

medicine
see medicinal product
medium

material on which data is stored (e.g., a magnetic disk)

medium

material on which data is stored (e.g., a magnetic disk)

multi-disciplinary care plan
see multi-professional care plan
multi-professional care plan

care plan encompassing healthcare provider activities performed by healthcare professionals having different healthcare professional entitlements

multi-professional healthcare plan
see multi-professional care plan

 N

needed care activity
see needed healthcare activity
needed healthcare activity

healthcare activities bundle which includes those healthcare activities assessed as needed to address specified health need

next of kin

person role being either the closest living relative of the subject of care or identified as the one he has a close relationship with

non-ratified healthcare information

healthcare information the relevance of which has not been assessed and explicitly stated as valid by a healthcare professional

non-verified condition
see excluded condition

 O

observed condition

health condition observed by a healthcare actor

observed health condition
see observed condition
order
see request
organization

unique framework of authority within which a person or persons act, or are designated to act towards some purpose

organization role

role (3.3.5) of an organization (3.3.1)

organizational pattern

relationships between the various parts of an organization

organizational role

role undertaken by an organization

other carer

healthcare third party having person role

outcome
see output health state
output health state

health state when a healthcare process ends

 P

party

person or group performing a role (3.3.5) in relation to the business of a specific community or domain

pathway of care
see clinical pathway
patient
see subject of care
patient summary repository
see summarized healthcare information repository
period of care
see mandated period of care
period of healthcare
see mandated period of care
person

human being regarded as an individual

person

human being regarded as an individual

person role

role of a person

personal health record

health record held and maintained by the subject of care or a subject of care proxy

physical quantity value

data value used for representing a quantity expressing the result of a measuring

point in time value

data value used for representing a point in time with minimum resolution year, and maximum resolution fraction of second

point of care

location where direct healthcare activities are performed

potential health condition

possible future or current health condition described by a healthcare actor

prescribed self-care

self-care activity prescribed by a healthcare professional

prescribed third party activity

healthcare third party activity prescribed by a healthcare professional

process

set of interrelated or interacting activities that use inputs to deliver an intended result

process model

representation of a process (3.6.1)

product

output of an organization that can be produced without any transaction taking place between the organization and the customer

professional health record

health record held under the responsibility of one healthcare provider and maintained by one or several healthcare professionals

professionally assessed condition

observed condition assessed by a healthcare professional concerning the genesis, the course, the severity or the impact of the health state

professionally assessed health condition
see professionally assessed condition
prognostic condition

potential health condition representing the expected course of a health state as assessed by healthcare professionals

prognostic health condition
see prognostic condition
programme of care
see care plan
protocol

customized clinical guideline

 Q

quality assurance

part of quality management (3.5.2) focused on providing confidence that quality requirements will be fulfilled

quality control

part of quality management (3.5.2) focused on fulfilling quality requirements

quality in healthcare

degree to which healthcare (3.1.1) fulfils requirements related to defined quality characteristics

quality management

coordinated activities to direct and control an organization (3.3.1) with regard to quality

 R

real value

data value used for representing a rational number

reason for demand for care

subject of care or a subject of care proxy's perception of health needs motivating a demand for care

record component
see electronic health record component
record contact
see indirect healthcare activity period
referral

demand for care where a healthcare professional asks a healthcare provider to state a healthcare commitment for a care period mandate

request

demand for care where a healthcare professional asks a healthcare provider to perform one or more healthcare provider activities

resource

asset that is utilized or consumed during the execution of a process

resource delay

healthcare activity delay caused by resource constraints where there is no health condition delay

resultant condition

observed condition representing an output health state

risk

combination of the probability of an event and its consequences

risk condition

potential health condition representing an unintended future health state

risk health condition
see risk condition
role

function or position

ruled out condition
see excluded condition
ruled out considered condition
see excluded condition

 S

section

structure component used for creating hierarchical structures within a composition and with entries as leaf nodes

self-care activity

healthcare activity performed by the subject of care

self-care period

healthcare activity period where prescribed self-care is performed

service

service user
see subject of care
sharable data repository

data repository containing exclusively electronic health record extracts, accessible for duly authorized healthcare actors independent of their organizational affiliation and placed under the custody of a healthcare actor

simple text value

data value used for representing a sequence of Unicode characters and optionally the language of the text

specific healthcare information request
see healthcare information request
standardized care plan
see core care plan
string value

data value used for representing a sequence of Unicode characters

structure component

electronic health record component which contain one of more other electronic health record components

subject of care

healthcare actor with a person role; who seeks to receive, is receiving, or has received healthcare

subject of care agent
see subject of care proxy
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 preference delay

healthcare activity delay by the preference of the subject of care, where there is neither a health condition delay nor a resource delay

subject of care proxy

healthcare third party having person role with the right to take decisions on behalf of the subject of care

subject of healthcare
see subject of care
summarized healthcare information repository

data repository containing summarized information for healthcare coordination and the continuity of care

synonym

one of two or more terms denoting the same concept

system of concepts

set of concepts (3.2.1) structured according to the relations among them

 T

target condition

potential health condition representing health objectives and/or healthcare goals

target health condition
see target condition
term

verbal designation of a general concept in a specific subject field

time value

data value used for representing a time of day, without relating it to a particular day

 U

unintended event

phenomenon that is not part of the normal course of a process but might influence it

uniprofessional care plan

care plan limited to those healthcare provider activities performed by healthcare professionals having the same healthcare professional entitlement

uniprofessional healthcare plan
see uniprofessional care plan
URI value

data value used for identifying uniform resource according to the specifications in IETF RFC 2396

 W

working diagnosis

considered condition that one or more healthcare professionals have determined to be the most consistent with the currently known observed conditions

working hypothesis
see working diagnosis

The representation of a model conforming to the international standard ISO 13940 available through this site is provided by Oughtibridge Ltd.  It is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.  This work is based on a UML model prepared by Torbjørn Nystadnes of the Norwegian Directorate of Health, a subordinate agency of the Norwegian Ministry of Health and Care Services.