A system of concepts for the continuity of care
data value used for identifying uniform resource according to the specifications in IETF RFC 2396
URI value
unintended event that has negative influence upon healthcare processes
EXAMPLES
NOTE 1 'Iatrogenesis' or 'iatrogeny' is a common cause of adverse events. NOTE 2 Adverse events can occur during appropriate healthcare activities NOTE 3 Adverse events may cause harm
adverse event
set of healthcare activities performed in response to an adverse event
NOTE The purposes for adverse event management are usually two: one is to reverse the effect or minimize the consequences of the adverse event, another one is to prevent the kind of adverse event in the future.
adverse event management
arrangement to meet someone at a particular time and place
appointment
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
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 ED data type. This document only supports the Binary data value (ED.data), whose attribute is renamed to ATTACHMENT.value. The following attributes from the ISO 21090:2011 ED data type are not included in this document:
attachment value
base component documenting the details of an attestation of a set of electronic health record components
attestation information
documentation of the details of a revision of a base component
NOTE The audit information is a profile on ISO 27789:2013 Health informatics — Audit trails for electronic health records. The profile includes only the minimum set of attributes needed in EHR extracts.
audit information
provision in legislation that in certain circumstances may overrule the need for informed consent
NOTE A healthcare mandate requires either informed consent or authorization by law.
authorization by law
method of delivering healthcare initiated by a responsible healthcare actor and thereafter delivered automatically by an automatic medical device
EXAMPLE Activities performed by the machine during a long term Electrocardiography (“Holter recording”) programme, implanted cardiac defibrillator.
NOTE Automated healthcare is not a healthcare activity in its own right since the automatic medical device doesn't have the capacity to be responsible. It is the healthcare actor who initiates and reviews the automated healthcare that is responsible for safe use of the automatic medical device.
automated healthcare
medical device capable of performing automated healthcare activities
EXAMPLES A specific identifiable Electrocardiography machine, electronic blood-sugar monitor.
NOTE In EN 13940-1:2007 the concept healthcare device was a specialization of healthcare actor and defined as 'device or equipment, possibly including a piece of software, involved in the provision of healthcare activities'.
automatic medical device
abstract class that include the properties common for all revisable classes included in EHR extract
base component
data value used for representing the values of two-valued logic
boolean value
healthcare period mandate
care mandate
healthcare mandate commissioning a mandated period of care
NOTE 1 A care period mandate may be an agreement between the subject of care and a healthcare provider to provide specified healthcare services in a mandated period of care. NOTE 2 In EN 13940-1:2007 care mandate was the preferred term for this concept.
care period mandate
healthcare plan
programme of care
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
EXAMPLE A care plan for retinopathy in diabetics by video-retinoscopy, which involves the GP and an ophthalmologist and implies specific mobile equipment (video-retinoscope) with a camera.
NOTE 1 A care plan may be recorded in one or more health records. NOTE 2 A care plan could be subdivided from different perspectives by different constraints. One example is uniprofessional care plan, for example, a nursing care plan with the constraint of only one specific healthcare professional involved. Other examples of specific constraints for a care plan are: care plan to address one health issue, one health condition, one contact, one clinical process, healthcare activities to be performed by one healthcare provider, etc. NOTE 3 Care plans are reviewed repeatedly during a healthcare process, each review based on a new healthcare needs assessment. NOTE 4 The healthcare activities in a care plan follow a life cycle. Examples of statuses of such a life cycle are: 'planned', 'performed', 'cancelled', etc.; all of these statuses are included in the care plan. NOTE 5 In EN 13940-1:2007 programme of care was the preferred term for this concept.
care plan
official document issued by a healthcare actor attesting healthcare matters relating to a subject of care
EXAMPLES Birth certificate, death certificate, health certificate, health insurance certificate
certificate related to a healthcare matter
care 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
EXAMPLES Clinical guidelines related to hypertension, diabetes, pregnancy follow-up, Caesarean section; pressure area management, exercise programmes, social intervention programmes for people with a learning disability
NOTE 1 Clinical guidelines are usually rather generic and they concern no actual subject of care in particular. While they generally reflect a broad statement of good practice, they may sometimes include multiple operational details. NOTE 2 Clinical guidelines should be structured and contain standard criteria and indicators for measurement.
clinical guideline
care pathway
care map
pathway of care
pathway for the healthcare activities informing the content of core care plans
NOTE 1 The concept clinical pathway includes subtypes, for example, 'integrated care pathways', 'multidisciplinary pathways of care', 'collaborative care pathways'. NOTE 2 Clinical pathways are designed to support healthcare administration and healthcare resource management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions, etc.).
clinical pathway
healthcare process encompassing all healthcare provider activities and other prescribed healthcare activities that addresses identified or specified health issues
NOTE 1 As such, a clinical process is a set of interrelated or interacting healthcare activities, which are performed for a subject of care with one or more health issues. NOTE 2 The primary input and output to a clinical process is the health state. NOTE 3 In a clinical process a subject of care and healthcare professionals interact in all types of healthcare activities. NOTE 4 A clinical process comprises all kinds of healthcare activities, mainly healthcare provider activities, but also self-care activities as prescribed or recommended by healthcare professionals. NOTE 5 The clinical process can be regarded as the key type of process to support continuity of care from the perspective of the subject of care. NOTE 6 Clinical processes are the essential, central and most important type of healthcare processes. NOTE 7 A relevant distinction exists between the primary input (the subject of care's initial health state) and secondary or ancillary inputs (the resources brought in to perform the clinical process).
clinical process
health related period that includes all healthcare activity periods in one clinical process
clinical process episode
health thread comprising all healthcare matters related to a specific clinical process
NOTE A clinical process interest makes it possible
clinical process interest
clinical process mandate
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
NOTE 1 The subject of care and healthcare professionals are the main contributors to a clinical process outcome evaluation. NOTE 2 The target condition represents a requirement for the clinical process.
clinical process outcome evaluation
health record extract conveying specifically focused healthcare information in order to fulfil current information needs of the recipient
EXAMPLES lab report, X-Ray report
clinical report
structure component used for creating hierarchical structures within an entry and with elements as leaf nodes
cluster
data value used for representing a code in a code system implied and fixed by the context in which this data value occurs
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 CS data type.
coded simple value
data value used for representing a code in a referenced code system
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 CD.CV data type.
coded value
action resulting in an obligation by one or more of the participants in the act to comply with a rule or perform a contract
NOTE 1 to entry: The enterprise object(s) participating in an action of commitment may be parties or agents acting on behalf of a party or parties. In the case of an action of commitment by an agent, the principal becomes obligated.
commitment
structure component containing information composed during one clinical encounter or documentation session, and committed within one EHR
composition
unit of knowledge created by a unique combination of characteristics
concept
capability of the subject of care and/or the subject of care proxy to give informed consent or dissent
consent competence
considered health condition
potential health condition considered by a healthcare actor on the basis of one or more observed conditions
EXAMPLES Diagnostic hypothesis, any candidate in a differential diagnosis set.
NOTE 1 A request for care normally includes a health condition or symptom observed by the subject of care and also a question about what the reason for that symptom might be. It is the potential health condition in this question (the health condition behind the symptom) that is called a considered condition. NOTE 2 A referral within a clinical process is normally motivated by one or several observed conditions and/or professionally assessed conditions. However the referral also normally includes a question that the healthcare investigation is supposed to get an answer to. The question formulated as a potential condition is a considered condition. NOTE 3 A considered condition remains considered until the associated observed conditions are changed or completed. Healthcare investigation and/or healthcare treatment result in new observations that can verify or not verify the (suspected) considered condition. When a considered condition is verified it is transformed into an observed condition and/or professionally assessed condition that also could be labelled as a working diagnosis. If a considered condition cannot be verified by relevant healthcare activities it is transformed into an excluded condition. NOTE 4 A working diagnosis is often identified in the clinical process as a summary after the planned healthcare investigation are completed. A working diagnosis in this stage is often called a diagnosis. An excluded condition could correspondingly be called a negation of a working diagnosis.
considered condition
healthcare contact
interaction between a subject of care and one or more healthcare personnel
contact
encounter
healthcare activity period during which a contact occurs
EXAMPLES Face to face contact with a GP, telephone contact, telemedicine contact.
NOTE 1 Since during a contact, more than one health issue may be addressed, it may relate to more than one healthcare process and more than one episode of care. NOTE 2 In EN 13940-1:2007 the concept encounter was defined as 'contact in the course of which healthcare activities are delivered to a subject of care in her or his presence'.
contact period
abstract structure component that holds all properties common for sections and entries
content
continuity facilitator commission
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
EXAMPLE A mandate assigned to a coordinating nurse, to a lead GP, key-worker, etc. to coordinate care
NOTE 1 Beyond solely assuming the function described above, a continuity facilitator may also assume the function of a lead and/or coordinator of healthcare activities delivered to the subject of care NOTE 2 A continuity facilitation can be fulfilled only if the involved healthcare actors have the information needed to perform their tasks in healthcare activities NOTE 3 For continuity of care the continuity facilitator mandates for complete clinical processes are of special importance from the subject of care's perspective.
continuity facilitator mandate
efficient, effective, ethical care delivered through interaction, integration, co-ordination and sharing of information (3.9.5) between different healthcare actors over time
NOTE 1 to entry: Healthcare actor is defined in 5.2.1
continuity of care
standardized care plan
reusable content and structure for a potential care plan for a specified set of circumstances
NOTE 1 A core care plan is usually based upon knowledge in clinical guidelines (including protocols). NOTE 2 Core care plans can be applied in healthcare planning as a clinical process management method. NOTE 3 A core care plan may include advanced formulated schemes for recommended healthcare activities.
core care plan
reinterpretable representation of information (3.9.5) in a formalized manner suitable for communication, interpretation or processing
NOTE 1 to entry: Data are defined without any context in such a way that by itself one cannot tell its correct meaning, where it has meaning this is information (3.9.5).
data
an identifiable data storage facility
NOTE 1 to entry: In ISO 10303-22:1998 this is the definition of repository
data repository
data contained in an element
data value
data value used for representing a precise point in time with a resolution of second and optionally fraction of second
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 TS.DATETIME.FULL data types.
date time value
data value used for representing a point in time with a resolution of day of month
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 TS.DATE.FULL data type.
date value
demand for healthcare
demand for healthcare provider activities expressed by a healthcare actor
NOTE 1 A demand for care may be expressed either by the subject of care or on their behalf. NOTE 2 A healthcare provider may accept or decline a demand for care. NOTE 3 A demand for care could result in a healthcare assessment concluding that no other healthcare activity elements (as healthcare investigations and/or healthcare treatments) should be performed.
demand for care
first demand for care concerning one or more specific health issues to be assessed by a healthcare provider
demand for initial contact
demand commission
healthcare mandate implying the right and obligation to demand healthcare activities
NOTE 1 A demand for care is usually made by a subject of care him/herself, but there are circumstances where the subject of care is not in the position of making a demand for care. In that case, it has to be made on their behalf by another person. NOTE 2 Within certain jurisdictions a generic demand mandate may be explicitly or implicitly assigned to certain categories of citizens on the basis of their specific roles. It may also be directly or indirectly made necessary by law that such generic mandates are explicitly established.
demand mandate
structure component used for creating hierarchical structures within an demographic entry and with demographic elements as leaf nodes
demographic cluster
record component within a demographic entity or demographic cluster containing a single data value
demographic element
structure component containing demographic information describing a single person, device, software agent or organisation
demographic entity
demographic information extracted for the purpose of being included in an EHR extract or an EHR audit log extract
demographic extract
structure component used for creating hierarchical structures within a demographic extract and with demographic entities as leaf nodes
demographic folder
abstract structure component that holds all properties common for demographic clusters and demographic elements
demographic item
term rejected by an authoritative body
deprecated term
clinical report concerning a completed, mandated period of care
EXAMPLE Discharge letter
discharge report
discharge report summarizing a mandated period of care
NOTE 1 A discharge summary may be provided to the subject of care. NOTE 2 One mandated period of care may be immediately followed by another; the next mandated healthcare provider will then be a main recipient of the discharge summary. NOTE 3 Discharge summaries are often meant to be processed so as to categorize hospital stays according to a statistically designed classification (such as the Diagnosis-Related Groups (DRGs) or other systems), usually for funding or epidemiological purposes.
discharge summary
refusal to permit specific healthcare activities to be performed
dissent
data value used for representing a lapse of time
NOTE This specialization is equivalent to ISO 21090:2011 PQ.TIME data type. The translation and coding rationale attributes have been removed.
duration value
repository of information (3.9.5) regarding the health of a subject of care in computer processable format
NOTE 1 to entry: Subject of care is defined in 5.2.1
electronic health record
health record component which only includes information in electronic format
electronic health record component
health record extract consisting solely of electronic record components
electronic health record extract
electronic health record extract containing essential healthcare information intended for specific uses
EXAMPLES epSOS patient summary (EU), clinical summary (US), continuity care record (US), an electronic patient summary providing a healthcare professional with essential information needed for coordinated healthcare
electronic patient summary
electronic health record component within an entry or cluster containing a single data value
element
structure componentthat 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.
entry
episode of healthcare
health issue related episode
health related period during which healthcare activities are performed to address one health issue as identified by one healthcare professional[
EXAMPLES An episode of urinary tract infection, an episode of cholecystectomy.
NOTE 1 An episode of care encompasses all healthcare activity period elements related to the same health issue. NOTE 2 An episode of care starts with the very first contact with a healthcare provider for a health issue and it ends after the completion of all healthcare activities related to the last contact with that healthcare provider for the same health issue. NOTE 3 For practical reasons (e.g. the need to state start and end dates) and also because it relates specifically to a health issue defined by a given healthcare professional, an episode of care does not necessarily coincide with an 'episode of illness' (or of disease, or of any other kind of health issue). NOTE 4 During a mandated period of care several health issues may be handled and as such be linked to several episodes of care. These episodes of care are said to be 'concurrent'.
episode of care
episodes of healthcare bundle
cumulative episode of care
group of episodes of care delineated by a health thread
EXAMPLES A cumulative episode of diabetes mellitus, a cumulative episode of breast cancer.
NOTE 1 An episodes of care bundle starts with the very first contact with a healthcare provider for a health issue considered in a health thread and ends after the completion of all healthcare activities related to the last contact with any healthcare provider for a health issue encompassed in the same health thread. NOTE 2 As different health threads may be considered that reconcile the perspectives of different healthcare actors (e.g. a care team manager, or a health authority) or sets of healthcare actors, there may exist different health threads according to the specific perspectives of those sets of healthcare actors that justify building up such health threads. As a consequence there may exist as many episodes of care bundles as there are such health threads. NOTE 3 From the electronic health record point of view, an episodes of care bundle shows the overall healthcare activity period elements related to those health issues that are linked by the same health thread. NOTE 4 In EN 13940-1:2007 cumulative episode of care was the preferred term for this concept.
episodes of care bundle
discounted condition
non-verified condition
ruled out condition
ruled out considered condition
considered condition that one or more healthcare professionals have determined not to be consistent with the known observed conditions
excluded condition
base component that describes an association from information in an EHR extract to information outside that EHR extract
external link
structure component extracted from an EHR for the purpose of being communicated in an EHR extract as the target of one or more links
extracted component set
structure component used for creating hierarchical structures within an EHR extract and with compositions as leaf nodes
folder
health
healthcare approach
goal-addressing episode of care
episode of care during which the healthcare activities performed address one specific healthcare goal
health approach
health record extract that includes all health record components associated with a health thread for a specific concern
EXAMPLE Concern tracker (HL7).
NOTE 1 A concern is gathered information to support continuity of care for a subject of care. A health thread can include healthcare activities, health conditions, healthcare activity planning, activity management, evaluations and assessments. Thereby, all information needed for continuity of care for an individual subject of care can be covered by a health concern. NOTE 2 Health concerns can be constructed to support continuity of care for healthcare processes, clinical processes and accumulations/associations of clinical processes. This means that concerns can relate to episodes of care, contacts, chronic disease management, multiple chronic disease management, etc. NOTE 3 Health concerns can be represented and labelled in EHR as extracts or components. NOTE 4 Health concern is closely related to the “concern tracking” based on HL7 standards.
health concern
observed or potential observable aspects of the health state at a given time
EXAMPLES A health problem, diagnosis: an acute myocardial infarction (professionally assessed condition); a symptom: a head ache (observed condition).
NOTE 1 In the perspective of healthcare, the term health condition is often used to label a harmful or adverse condition (diseases, disorders, injuries, etc.), because it may motivate certain healthcare activities. NOTE 2 A health state is an object, a perception of which is a health condition. The underlying health state is nevertheless present even if not perceived by an observer, for example, the subject of care having a cancer before it gives symptoms. NOTE 3 In a clinical process, the health state of the subject of care is process input and also the process output. The evolving health state follows a life cycle and along its successive steps, is observed as different health conditions: initial, observed condition, considered condition, professionally assessed condition, resultant condition (the outcome of the process), evaluated. NOTE 4 A diagnosis is a way to describe and label certain types of health conditions. NOTE 5 Health condition may relate to a past, present or potential future health state. NOTE 6 A health condition is a health issue and as such is a representation of aspect(s) of the health state.
health condition
healthcare activity delay caused by a health condition
EXAMPLE 1 surgery delayed because the subject of care is pregnant EXAMPLE 2 cervical examination delayed during menstruation
health condition delay
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 evolution
health related period during which a health condition has been observed
NOTE 1 Observation of a health condition may lead to an episode of care NOTE 2 Health condition period refers only to the observation of the health condition, for example, the time interval during which a subject of care has observed a bleeding. The concept episode of care is referring to the healthcare activities.
health condition period
representation of an issue related to the health of a subject of care as identified by one or more healthcare actors
EXAMPLES A loss of weight, a heart attack, a drug addiction, an injury, dermatitis.
NOTE According to this definition, a health issue can correspond to a health problem, a disease, an illness or another kind of health condition.
health issue
deficit in the current health state compared to aspects of a desired future health state
NOTE 1 A health need is the deficit in a subject of care’s health state. NOTE 2 The current health state is observed as observed conditions. NOTE 3 The desired future health state can be a health objective expressed as target conditions. NOTE 4 The health need can be identified and formulated by the subject of care or by any other healthcare actor. NOTE 5 Health needs are the motivations/indications for healthcare activities and are the basic input to healthcare needs assessments.
health need
intended outcome
desired ultimate achievement of a healthcare process addressing health needs
NOTE A health objective could be expressed as one or several target conditions to be reached within a specified date and time.
health objective
health condition considered by a healthcare actor to be a problem
EXAMPLES Diabetes, stroke, heredity for breast cancer.
NOTE Health problems can be single observations but are usually more compound as a summary of several observations. Single observations are often criteria for the more compound health condition considered to be a health problem.
health problem
healthcare problem list
health thread linking a set of health problems
health problem list
data repository regarding the health and healthcare of a subject of care
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.
health record
part of a health record that is identifiable for the purposes of referencing and revision
NOTE 1 This International Standard defines one health record component specialization, the electronic record component. However, as the content of a health record is not limited to information in electronic format, the content of health record components may be in formats other than electronic. NOTE 2 A health record component may itself result from an aggregation of multiple health record components.
health record component
part or all of a health record extracted for the purpose of communication
NOTE 1 This International Standard defines one health record extract specialization - the electronic record extract. However, as the content of a health record is not limited to information in electronic format, the content of health record extracts may be in formats other than electronic.
health record extract
time interval related to the health of a subject of care and/or the provision of healthcare for that subject of care
NOTE 1 A health related period may be specialized in relation to a number of situations – a specific clinical process, healthcare professional, a specific department, a specific health issue, etc. NOTE 2 A health related period is delineated by a 'start date and time' and an 'end date and time'. While the statement of the start date is generally easy by definition, the identification of the end date may be subject to specific rules that have to be agreed upon locally.
health related period
physical and mental functions, body structure, personal factors, activity, participation and environmental aspects as the composite health of a subject of care
NOTE 1 An observation of a health state is a health condition. A health state may possibly give way to more than one observation, resulting in more than one health condition. The underlying health state is nevertheless present even if not perceived by an observer, for example, the subject of care having a cancer before it gives symptoms. NOTE 2 In ICF (the International Classification of Functioning, Disability and Health) of the WHO, the concept of health is described. ICF identifies five health components; body function, body structure, activity, participation and environmental factors.
health state
defined association between healthcare matters as determined by one or more healthcare actors
NOTE 1 A health thread reconciles a range of healthcare matters reflecting the variety of scopes of healthcare actors, particularly of healthcare providers. NOTE 2 A health thread inherently associates the healthcare processes as well as the healthcare activity period elements referring to those healthcare matters. NOTE 3 A health thread may be established by a team (e.g. a coordination committee). NOTE 4 A health thread can be built step-by-step, by allowing each healthcare professional to add their perspective into a common health thread. NOTE 7 Under the responsibility of a designated healthcare actor, a health thread linking several healthcare matters can describe an episodes of care bundle, for instance, a partial or comprehensive synthesis of healthcare actor related episodes of care. NOTE 8 A collective decision (before, during or after the healthcare interventions) may define a health thread and so the idea of the 'episode' accepted by all the healthcare professionals involved. NOTE 9 Two health conditions may sometimes only be recognized as belonging to the same health thread late in the process of care. Conversely, two health conditions thought initially to belong to the same health thread may need to be separated later. NOTE 10 Since a health thread links any number of healthcare matters; it also may link health threads linking other health issues. Hence, a health thread may be considered an aggregation of health issues and/or health threads.
health thread
care activities, services, management or supplies related to the health of an individual
NOTE 1 to entry: This includes more than performing procedures for subjects of care . It includes, for example, the management of information about patients, health status and relations within the healthcare delivery framework and may also include the management of clinical knowledge.
healthcare
set of healthcare activities
EXAMPLE All healthcare activities provided to a subject of care in provision of, during and in the aftermath of a planned surgical operation, in relation to that operation.
NOTE A healthcare activities bundle may be delineated using a health thread comprising healthcare activities.
healthcare activities bundle
activity intended directly or indirectly to improve or maintain a health state
EXAMPLE A blood pressure measurement completed by a qualified nurse including the healthcare activity elements of taking, documenting and evaluation.
NOTE 1 Each specialization of this concept represents healthcare activities performed by a specialization of healthcare actor. NOTE 2 Different types of healthcare activity elements (e.g. healthcare investigation or healthcare treatment) may be performed during a healthcare activity. NOTE 3 See the concepts healthcare provider activity, self-care activity, healthcare third party activity and automated healthcare when it comes to the recording of information that are the result of healthcare activities (e.g. ratified observations).
healthcare activity
health related period during which a healthcare activity is planned but not started
healthcare activity delay
directory of the healthcare activities offered by a healthcare provider
NOTE 1 The healthcare activity directory includes those healthcare activities that the healthcare provider's healthcare personnel can perform, not those that are actually available at the time of healthcare delivery. The ability to perform a healthcare activity implies that the healthcare provider has the necessary resources. NOTE 2 The healthcare activity directory is related to the management of healthcare processes. NOTE 3 Healthcare providers may also have a healthcare service directory This directory includes the services that can be delivered by healthcare processes using the healthcare activities included in the healthcare activity directory.
healthcare activity directory
element of healthcare activity that addresses one type of purpose
NOTE Healthcare activity is a complex concept that can be subdivided in elements that represent different purposes with the action. The different purposes could be direct (healthcare investigation and healthcare treatment that directly involves the subject of care) or indirect (healthcare assessment, healthcare evaluation, healthcare documenting or healthcare activity management that do not necessarily directly involve the subject of care.
healthcare activity element
healthcare activity element during which the status of healthcare activities in a care plan are changed
NOTE Examples statuses for healthcare activities are; planned, scheduled, resource allocated, ongoing, performed/finished, evaluated.
healthcare activity management
healthcare activity commission
healthcare mandate assigning the right and obligation to perform specific healthcare activities
healthcare activity mandate
time interval during which healthcare activities are performed for a subject of care
NOTE In EN 13940-1:2007 contact was the preferred term for this concept.
healthcare activity period
contact element
part of a healthcare activity period during which one health issue is specifically addressed
EXAMPLE The part of a consultation that addresses the follow-up of a hypertension treatment, but not the other part of the same consultation that is devoted to the treatment of diabetes mellitus.
NOTE 1 Several healthcare activity period elements may take place during the course of a healthcare activity period. NOTE 2 A healthcare activity period element is part of only one healthcare activity period and of only one episode of care. NOTE 3 In EN 13940-1:2007 contact element was the preferred term for this concept.
healthcare activity period element
healthcare party
organization or person participating in healthcare
NOTE 1 The involvement of the healthcare actor will be either direct (for example, the actual provision of care), or indirect (for example, at organizational level). NOTE 2 According to this definition, people or organizations responsible for the funding, payment, or reimbursement of healthcare provision are healthcare actors, as well as organizations responsible for healthcare delivery. NOTE 3 In EN 13940-1:2007 healthcare party was the preferred term for this concept.
healthcare actor
administrative activities related to healthcare processes
EXAMPLES Budgeting and resource allocation, organizational structure, non-clinical documentation, administrative activity management, resource management, etc.
NOTE Administrative activities are indirect activities in a healthcare process and include support and management.
healthcare administration
appointment for a contact
healthcare appointment
healthcare activity element where an opinion related to health conditions and/or healthcare activities is formed
healthcare assessment
care commitment
acceptance of a healthcare mandate by the healthcare actor to whom it is assigned
NOTE 1 The healthcare commitment is the promise by the healthcare actor to perform healthcare activities. This also means that the healthcare provider accepts and confirms the pending healthcare mandate issued through the proposed care plan. NOTE 2 Implicitly, a healthcare commitment results from a dialogue with the subject of care or someone on behalf of the subject of care within a healthcare needs assessment
healthcare commitment
healthcare activity element where at least two healthcare actors communicate
healthcare communication
data (3.9.1) produced during healthcare activities
NOTE 1 to entry: Healthcare activity is defined in 7.2
healthcare data
healthcare activity element where health records are created or maintained
healthcare documenting
care employment
contractual framework between a healthcare personnel and a healthcare organization describing the roles and responsibilities assigned to that healthcare personnel
healthcare employment
healthcare activity element where aspects of at least one other healthcare activity element is evaluated
NOTE 1 Healthcare evaluation may be performed by all kinds of healthcare actors, including the subject of care. NOTE 2 See also clinical process outcome evaluation.
healthcare evaluation
care funds
resource provided for funding healthcare delivery
NOTE Funds may be provided by, for example, a health insurance fund, a governmental agency, a national or local authority, a welfare programme, the subject of care or any other person or organization having a role in the funding of healthcare.
healthcare funds
desired achievement of one or more healthcare activities, considered as an intermediate operational step to reach a specific health objective
NOTE A healthcare goal could be expressed as one or several target conditions to be reached within a specified date and time.
healthcare goal
information about a person, relevant to his or her healthcare
healthcare information
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 for import
specific 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
NOTE 1 In order to fulfil the request, a mandate to export personal information is needed. NOTE 2 In EN 13940-1:2007 specific clinical information request was the preferred term for this concept.
healthcare information request
healthcare activity element with the intention to clarify one or more health conditions of a subject of care
NOTE 1 Healthcare investigations add and improve information about aspects of a health state. NOTE 2 Some primary healthcare investigations can sometimes have an intended or secondary therapeutic effect, while some activities can be both investigating and therapeutic by essence (e.g. a fibroscopy, interventional cardiology, etc.)
healthcare investigation
healthcare commission
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
NOTE 1 A healthcare mandate can be explicit or implicit NOTE 2 Relevant information related to healthcare mandates (including demands for care, informed consents, dissents, healthcare commitments, etc.), is recorded in health records where the information is made available for concerned healthcare actors as health concerns. NOTE 3 Typically a healthcare mandate is assigned by one healthcare actor to another. NOTE 4 In EN 13940-1:2007 health mandate was the preferred term for this concept.
healthcare mandate
care 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
EXAMPLES A loss of weight, an immunization, a heart attack, a drug addiction, a case of meningitis in the school, a water fluoridation, a health certificate, an injury, dermatitis, an X-ray investigation, an arthroscopy, an administration of an oral antibiotic, a post-operative infection.
NOTE 1 Healthcare matter is a very broad and flexible concept that includes anything related to the health or the healthcare of a subject of care. This means that health conditions, healthcare activities, health problems, the result of healthcare activities, etc. all are possible to be identified as healthcare matters. Thereby healthcare matter might have several specializations and further associations. NOTE 2 According to this definition, a healthcare matter can represent a disease, an illness or another kind of health condition. In addition a healthcare matter may represent, for example, a request for a procedure (therapeutic or preventive) by the subject of care or another healthcare actor. NOTE 3 Concepts described and/or identified in a clinical terminology may represent types of healthcare matter. NOTE 4 Other specializations of this concept than those included in this International Standard, may be created when needed.
healthcare matter
healthcare assessment during which a healthcare professional considers a subject of care’s health need and determines the needed healthcare activities
NOTE 1 A healthcare needs assessment precedes healthcare planning. NOTE 2 Healthcare needs assessments should be performed in a dialogue with the subject of care. The responsibility for a healthcare needs assessment is held by a healthcare professional. NOTE 3 The subjects of care interact with healthcare professionals in healthcare needs assessments and also describe their opinions on which healthcare activities should be asked for in a demand for care.
healthcare needs assessment
care organization
healthcare delivery organization
healthcare provider having an organization role
EXAMPLES A care team, a group practice, a hospital, a hospital department, a hospital care unit, self-employed GP
NOTE 1 Groupings or subdivisions of an organization, such as departments or sub-departments, may also be considered as organizations where there is need to identify them. The internal structure of an organization is described by its organizational pattern. NOTE 2 Effectively, a healthcare organization relies on the activity performed by healthcare personnel, whether employed, contracting, or with temporary informal though functional relationships between them. A healthcare team working together, for example, a specific type of clinical process with participants from different departments is also a kind of healthcare organization. NOTE 3 A free-standing self-employed solo practising healthcare professional shall be considered as the only member of his/her own healthcare organization. NOTE 4 Organizations may have a number of different roles. When an organization acts in a role where its healthcare personnel participate in the direct provision of healthcare, it is called a healthcare organization.
healthcare organization
care personnel
individual provider
individual healthcare actor having a person role in a healthcare organization
EXAMPLES GP, medical consultant, therapist, dentist, nurse, social worker, radiographer, nurse’s assistant, children’s nurse, nursing officer, head of department, social worker, medical consultant, etc.
healthcare personnel
care planning
element of healthcare activity management where a care plan is created or modified
healthcare planning
care process
set of interrelated or interacting healthcare activities which transforms inputs into outputs
NOTE 1 The main type of healthcare process is the clinical process that has a health state as input and output and includes all activities in relation to one or more specified health issues. NOTE 2 A healthcare process is not by definition restricted to one healthcare provider or any other organizational unit borders.
healthcare process
healthcare evaluation where healthcare processes are systematically assessed against requirements
NOTE 1 The outputs of clinical processes are evaluated in a clinical process outcome evaluation. NOTE 2 Requirements are defined as a combination of needs and expectations that are stated, generally implied or obligatory. The needs can be represented by, for example, target conditions, goals for resource consumption, compliance to guidelines, etc. The expectations can be represented by the perceptions of the outcomes from each of the involved healthcare actor’s perspective (i.e. subject of care and healthcare professionals).
healthcare process evaluation
care professional
health professional
healthcare personnel having a healthcare professional entitlement recognized in a given jurisdiction
EXAMPLES GP, medical consultant, therapist, dentist, nurse, radiographer, etc.
NOTE The healthcare professional entitlement entitles a healthcare professional to provide healthcare independent of a role in a healthcare organization.
healthcare professional
care professional entitlement
registered authorization given to a person in order to allow the person to have or perform specific roles in healthcare
EXAMPLES Diploma, professional registration (e.g. registered nurse).
NOTE 1 Entitlement is usually backed by evidence of having received, or continuously receiving, the necessary qualification, the relevant education and training. NOTE 2 The official entitlement of a healthcare professional forms the foundation for his/her official duties and rights.
healthcare professional entitlement
care provider
health provider
health service provider
healthcare service provider
healthcare actor that is able to be assigned one or more care period mandates
NOTE 1 The personnel of a healthcare organization that is a healthcare provider may include both healthcare professionals and others which participate in the provision of healthcare. NOTE 2 This International Standard includes only two specializations of healthcare provider. This is not meant to exclude the possibility of other specializations. In jurisdictions where other kinds of healthcare actors are included in the concept of healthcare provider, the necessary specializations may be added. NOTE 3 According to this definition, organizations solely responsible for the funding, payment, or reimbursement of healthcare provision are not healthcare providers; for the purpose of this International Standard they are considered as healthcare third parties.
healthcare provider
healthcare activity performed by a healthcare provider
NOTE 1 A healthcare provider activity can be performed in relation to several healthcare activity period elements of the same healthcare activity period. NOTE 2 When the healthcare provider is a healthcare organization, the healthcare activities are performed by the healthcare personnel of that healthcare organization.
healthcare provider activity
clinical governance
coordinated activities to direct and control a healthcare organization with regard to quality
EXAMPLES Direct and control the fulfilment of requirements in quality criteria repositories, changing behaviour of healthcare professionals.
NOTE 1 The clinical processes are the most important type of healthcare processes related to healthcare quality management. NOTE 2 Healthcare quality management activities include the establishment of a quality policy, setting quality objectives, the performance of audits, evaluation and a feedback loop for quality improvement, all resulting in quality assurance.
healthcare quality management
resource needed to perform healthcare activities
EXAMPLES Healthcare professional on duty, operation theatre, instruments ready to use, consultation rooms, bed in a ward, prepared medicinal products, Electrocardiography-device, blood sample, donated kidney, etc.
NOTE As a healthcare process develops, the healthcare resources follow a life cycle. Examples of steps of such a life cycle are: 'available', 'booked', 'provided', ''in use', 'consumed', etc.
healthcare resource
activities to direct and control the supply and use of the healthcare resources required to perform healthcare activities
healthcare resource management
service that is the result of a healthcare process
EXAMPLE Diagnostic investigation and result report.
NOTE Comprehensive healthcare services intended for specified health issues are results of clinical processes.
healthcare service
directory of the types of healthcare services offered by one or more healthcare providers
healthcare service directory
care supporting organization
healthcare third party having organizational role
EXAMPLES Voluntary aid organization, a homecare service organization, a health insurance fund, the operator of a telemedicine system, family.
healthcare supporting organization
care third party
healthcare actor other than a healthcare provider or the subject of care
NOTE 1 According to this definition, a relative (family member) aiding the subject of care, any actor responsible for social support, or for the funding, payment, or reimbursement of healthcare provision are healthcare third parties. NOTE 2 Healthcare third party is an abstract superordinate generic concept which is only fully supported through the use of one of its subordinate specific concepts.
healthcare third party
healthcare contributing activity
healthcare activity performed by a healthcare third party
EXAMPLES The healthcare treatment of a bedsore by a subject of care's relation, healthcare treatment on advice by a chemist.
NOTE 1 There are two kinds of healthcare third party activities that should be distinguished. NOTE 2 In EN 13940-1:2007 healthcare contributing activity was the preferred term for this concept.
healthcare third party activity
healthcare activity element intended to directly improve or maintain a health state
NOTE 1 The treatment of a subject of care's health state, based on that subject of care's health conditions, is a part of the clinical process considered from a therapeutic perspective. NOTE 2 Healthcare treatment is intended to contribute to fulfilling the assessed health need. NOTE 3 Prevention is a type of healthcare treatment where the risk of a health condition is treated. NOTE 4 Healthcare treatment includes all types of activities that intend to influence the health state including, for example, rehabilitation, palliative care, education of subjects of care, caring, etc.
healthcare treatment
record contact
healthcare activity period without the involvement of the subject of care
EXAMPLE 1 The period where healthcare activities are performed without the presence of the subject of care in order to decide whether a referral or a demand for initial contact should be accepted or not EXAMPLE 2 Time spent working on laboratory or tissue specimens taken from a subject of care EXAMPLE 3 Period taken for the planning of care
NOTE 1 In EN 13940-1:2007 the concept record contact was defined as 'contact restricted to the access to the professional health record of a subject of care by a healthcare professional for its management, out of the presence of that subject of care'.
indirect healthcare activity period
knowledge concerning objects that within a certain context has a particular meaning
NOTE 1 to entry: Facts, events, things, processes, and ideas, including concepts, are examples of objects. NOTE 2 to entry: Information is something that is meaningful. Data might be regarded as information once its meaning is revealed.
information
formal model of a bounded set of facts, concepts or instructions to meet a specified requirement
information model
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
informed consent
contact during which a clinical process is initiated
initial contact
health state at the initiation of healthcare process
NOTE The output health state from one healthcare process may be the input health state to a subsequent healthcare process.
input health state
data value used for representing identifier that uniquely identifies an object
EXAMPLES EHR identifier, EHR system identifier, order id, service catalogue item id, Vehicle Identification, Number (VIN), driving licence identifier, US social security number, NHS number, Australian medicare number, etc.
NOTE 1 Instance identifiers are defined based on ISO object identifiers. NOTE 2 An identifier allows someone to select one record, object or thing from a set of candidates. Usually an identifier alone without any context is not usable. NOTE 3 This DATA_VALUE specialization is equivalent to ISO 21090:2011 II data type. The displayable, scope and reliability attributes have been removed.
instance identifier value
data value used for representing an exact integral values.
EXAMPLES -1, 0, 1, 2, 100, 3398129, etc.
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 INTEGER data type.
integer value
abstract structure component that holds all properties common for clusters and elements
item
cognizance which is based on reasoning and passes verification
knowledge
base component that describes an association from information in an EHR extract to other information within that EHR extract
link
commission to export personal information
healthcare mandate implying the right to communicate health record extracts
EXAMPLE 1 A request to a doctor to write a letter to a medical specialist stating the reasons of a referral EXAMPLE 2 A request to a GP by a subject of care for the transfer of his or her health record to another GP, when that subject of care moves to another part of the country.
mandate to export personal information
commissioned period of care
period of care
period of healthcare
set of healthcare activity periods where a healthcare provider is mandated to perform the healthcare activities required to address specific health needs
EXAMPLES A hospital stay, a series of radiotherapy sessions at an outpatient clinic.
NOTE 1 The mandated period of care is focused upon the framework of a care commitment of the provider as well as the mandate from the subject of care, which means that the roles and responsibilities of both the interacting parts are respected. NOTE 2 Whenever the healthcare provider considered in a mandated period of care is a healthcare organization, this mandated period of care encompasses all healthcare activity periods with healthcare professionals who have a role in that healthcare organization. NOTE 3 A mandated period of care may be part of another mandated period of care. NOTE 4 In EN 13940-1:2007 period of care was the preferred term for this concept. NOTE 5 The relevant information describing and produced during the healthcare activities performed as a part of a mandated period of care is recorded in one or more professional health records.
mandated period of care
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
NOTE 1 to entry: This definition has been developed by the Global Harmonization Task Force (GHTF) NOTE 2 to entry: Products, which could be considered to be medical devices in some jurisdictions but for which there is not yet a harmonized approach, are: NOTE 3 to entry: Accessories intended specifically by manufacturers to be used together with a “parent” medical device to enable that medical device to achieve its intended purpose, should be subject to this International Standard.
medical device
medicine
NOTE 1 to entry: A medicinal product may contain one or more manufactured items and one or more pharmaceutical products. NOTE 2 to entry: In certain jurisdictions a medicinal product may also be defined as any substance or combination of substances which may be used to make a medical diagnosis. NOTE 3 to entry: The provisions in this International Standard apply to proprietary medicinal products for human use intended to be placed on the market and to industrially manufactured medicinal products, the marketing of which has been authorized by a Medicines Regulatory Agency. However, the provisions do not apply to medicinal products prepared according to prescription, for instance, prepared in a pharmacy from a prescription intended for a specific patient; medicinal products prepared in accordance with an official formula, for instance, prepared in a pharmacy in accordance with the instructions in a pharmacopoeia and intended to be given direct to the patient by the pharmacy; medicinal products intended for research and development trials (see 3.1.28 Investigational Medicinal Product); intermediate products intended for subsequent processing by an authorized manufacturer.
medicinal product
material on which data is stored (e.g., a magnetic disk)
medium
medium (duplicate)
multi-professional healthcare plan
multi-disciplinary care plan
care plan encompassing healthcare provider activities performed by healthcare professionals having different healthcare professional entitlements
multi-professional care plan
needed care activity
healthcare need
care need
healthcare activities bundle which includes those healthcare activities assessed as needed to address specified health need
NOTE 1 A needed healthcare activity is a healthcare activity that is assessed by healthcare professionals to be motivated/indicated by the health need. NOTE 2 A needed healthcare activity is the outcome of healthcare needs assessments performed by healthcare professionals. Needed healthcare activities can be identified by any mandated healthcare professional performing healthcare needs assessment for a subject of care. NOTE 3 Needed healthcare activities are managed in a care plan.
needed healthcare activity
person role being either the closest living relative of the subject of care or identified as the one he has a close relationship with
NOTE 1 The person that is the next of kin may participate implicitly or explicitly in healthcare by sometimes being a subject of care proxy when the subject of care has impaired consent competence. Thereby in these circumstances a person that is next of kin can perform the role of a healthcare third party. NOTE 2 A person may play the role of next of kin to more than one subject of care
next of kin
healthcare information the relevance of which has not been assessed and explicitly stated as valid by a healthcare professional
NOTE 1 Healthcare information that has been received and is proposed for incorporation in a professional health record may not yet have been reviewed for validity or context by the healthcare professional, and as such its’ accuracy may remain arguable. In this respect, clinical ratification differs both from attesting information for the needs of an audit trail, or from committing information in the perspective of sending out messages containing healthcare information, outlined in EN ISO 13606-1:2008. NOTE 2 Regardless of the technical process meant practically, healthcare information cannot be 'inserted' into a professional health record unless ratified by a healthcare professional. Until a decision is made regarding their insertion or rejection, they are held in a secure temporary storage.
non-ratified healthcare information
observed health condition
health condition observed by a healthcare actor
EXAMPLES: A blood pressure, a swelling in the abdomen, tachycardia, body weight, lung infiltration on x-ray, a haemoglobin value, pale skin.
NOTE 1 Healthcare professionals and subjects of care are examples of healthcare actors that can perceive the observed aspect of a health state. NOTE 2 An observed condition is a health issue and as such is a representation of aspect(s) of the health state.
observed condition
unique framework of authority within which a person or persons act, or are designated to act towards some purpose
NOTE 1 to entry: Groupings or subdivisions of organizations may also be considered as organizations where there is need to identify them in this way for purposes of information interchange. NOTE 2 to entry: In this International Standard, this definition applies to any kind of organizations, whatever their legal status.
organization
role (3.3.5) of an organization (3.3.1)
organization role
relationships between the various parts of an organization
organizational pattern
role undertaken by an organization
organizational role
informal carer
healthcare third party having person role
EXAMPLES A relative (family member), a neighbour.
other carer
outcome
health state when a healthcare process ends
output health state
person or group performing a role (3.3.5) in relation to the business of a specific community or domain
party
human being regarded as an individual
person
person (term)
role of a person
person role
health record held and maintained by the subject of care or a subject of care proxy
personal health record
data value used for representing a quantity expressing the result of a measuring
NOTE 1 The general pattern for a measurement is value unit of Thing. In this scheme, the PHYSICAL_QUANTITY represents the value and the unit, and the Thing is described by some coded concept that is linked to the PHYSICAL_QUANTITY by the context of use. This maps obviously to some measurements, such as Subject of care Body Temperature of 37 Celsius, and 250 mg/day of Salicylate. NOTE 2 This DATA_VALUE specialization is equivalent to ISO 21090:2011 PQ data type. The translation and coding rationale attributes have been removed.
physical quantity value
data value used for representing a point in time with minimum resolution year, and maximum resolution fraction of second
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 TS.
point in time value
location where direct healthcare activities are performed
NOTE Location refers to the geographical location of the subject of care; not the body area of the subject of care that the treatment is applied to.
point of care
possible future or current health condition described by a healthcare actor
NOTE 1 A potential health condition is not yet observed, but represents an imagined, possible observation of aspects of a current or future health state. NOTE 2 A potential health condition can only be fully supported through the use of one of its specializations.
potential health condition
self-care activity prescribed by a healthcare professional
prescribed self-care
healthcare third party activity prescribed by a healthcare professional
prescribed third party activity
set of interrelated or interacting activities that use inputs to deliver an intended result
process
representation of a process (3.6.1)
process model
output of an organization that can be produced without any transaction taking place between the organization and the customer
product
health record held under the responsibility of one healthcare provider and maintained by one or several healthcare professionals
EXAMPLES Health records held at their surgery or at a health centre by a GP, by a medical specialist, by a nurse, in a hospital department at a patient's bedside, by a care team in an integrated clinical network, by a dentist.
NOTE The responsible healthcare provider may allow the subject of care to access and/or offer contributions to the professional health record.
professional health record
professionally assessed health condition
observed condition assessed by a healthcare professional concerning the genesis, the course, the severity or the impact of the health state
professionally assessed condition
prognostic health condition
potential health condition representing the expected course of a health state as assessed by healthcare professionals
prognostic condition
customized clinical guideline
EXAMPLES A protocol for a heart failure in an emergency department, a protocol for treatment and follow-up of urinary infections in children in a health centre.
NOTE 1 A protocol is more precise than a clinical guideline. NOTE 2 Protocols are often presented in a formal manner with respect to the expected behaviours and roles of healthcare actors.
protocol
part of quality management (3.5.2) focused on providing confidence that quality requirements will be fulfilled
quality assurance
part of quality management (3.5.2) focused on fulfilling quality requirements
quality control
degree to which healthcare (3.1.1) fulfils requirements related to defined quality characteristics
NOTE 1 to entry: Quality is defined in ISO 9000:2005, 3.11 as the 'degree to which a set of inherent characteristics fulfil requirements'
quality in healthcare
coordinated activities to direct and control an organization (3.3.1) with regard to quality
NOTE 1 to entry: Direction and control with regard to quality generally includes establishment of the quality policy and quality objectives, quality planning, quality control, quality assurance and quality improvement.
quality management
data value used for representing a rational number
NOTE This DATA_VALUE specialization is equivalent to ISO 21090:2011 REAL data type.
real value
subject of care or a subject of care proxy's perception of health needs motivating a demand for care
NOTE There are needs for both direct (healthcare investigating and healthcare treatment) and indirect (healthcare assessments, healthcare planning, healthcare evaluation, etc.) healthcare activities.
reason for demand for care
demand for care where a healthcare professional asks a healthcare provider to state a healthcare commitment for a care period mandate
EXAMPLE A referral from an orthopaedic surgeon to a rehabilitation service.
NOTE An accepted referral transfers the continuity responsibility for the health issues specified in the referral.
referral
order
healthcare provider activity request
demand for care where a healthcare professional asks a healthcare provider to perform one or more healthcare provider activities
EXAMPLE Request for a healthcare assessment, an operation, a wheelchair, etc.
NOTE 1 A request is put forward by a healthcare professional within a healthcare process. NOTE 2 The responsibility for the requested healthcare provider activities is held by the performer but they will be performed under the care period mandate of the requester. NOTE 3 A healthcare provider may accept or decline a request (order) to perform healthcare activities.
request
asset that is utilized or consumed during the execution of a process
EXAMPLES Time, personnel, human skills and knowledge, equipment, services, supplies, facilities, technology, data, money
NOTE 1 to entry: Resources may include diverse entities such as funding, personnel, facilities, capital equipment, tools, and utilities such as power, water, fuel and communication infrastructures. NOTE 2 to entry: Resources may be reusable, renewable or consumable.
resource
healthcare activity delay caused by resource constraints where there is no health condition delay
EXAMPLE 1 healthcare activity scheduled later than clinically indicated to allow resources to be deployed on other subjects of care (a waiting list) EXAMPLE 2 healthcare activity postponed while necessary financial resources are identified
resource delay
observed condition representing an output health state
EXAMPLES Healthcare process result, healthcare activity result
NOTE A resultant condition can represent the output health state after a single healthcare activity element, a bundle of healthcare investigations and/or healthcare treatments in a healthcare process and also the outcome after a complete clinical process.
resultant condition
combination of the probability of an event and its consequences
risk
risk health condition
potential health condition representing an unintended future health state
NOTE While a risk is defined as the combination of a probability of an event and its consequences, the risk condition deals only with the consequences.
risk condition
function or position
role
structure component used for creating hierarchical structures within a composition and with entries as leaf nodes
section
health self-care activity
healthcare activity performed by the subject of care
EXAMPLES Self injection of insulin, self-measurement of blood pressure, or of glycaemia.
NOTE 1 There are two kinds of self-care activities that should be distinguished. NOTE 2 In EN 13940-1:2007 health self-care activity was the preferred term for this concept.
self-care activity
healthcare activity period where prescribed self-care is performed
self-care period
service
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
NOTE 1 A sharable data repository has to be placed under the custody of a healthcare actor in order to assure and maintain its consistency. NOTE 2 In EN 13940-1:2007 sharable data repository was defined as 'electronic health record containing exclusively sharable data, placed under the custody of a healthcare party, to whom a continuity facilitator mandate has been delivered'.
sharable data repository
data value used for representing a sequence of Unicode characters and optionally the language of the text
NOTE This DATA_VALUE specialization is corresponds to a constrained ISO 21090:2011 ST.NT data type where the SN. translation attribute has been removed.
simple text value
data value used for representing a sequence of Unicode characters
string value
electronic health record component which contain one of more other electronic health record components
structure component
subject of healthcare
patient
client
service user
healthcare actor with a person role; who seeks to receive, is receiving, or has received healthcare
EXAMPLES A treated patient, a client of a physiotherapist, each particular member of a target population for screening, each particular member of a group of diabetic people attending a session of medical education, a person seeking health advice.
NOTE A fœtus may be considered as a subject of care when receiving healthcare.
subject of care
desire expressed by the subject of care or the subject of care proxy regarding the performance of certain healthcare activities
EXAMPLES No blood transfusion, cultural or religious preference, do not resuscitate, allow natural death
NOTE In quality management [ISO 9000:2005] requirement is defined as “needs and expectations that is stated generally implied or obligatory". The expectations reflect the subject of care's desires.
subject of care desire
healthcare activity delay by the preference of the subject of care, where there is neither a health condition delay nor a resource delay
EXAMPLE 1 surgery delayed to enable the subject of care to undertake seasonal work EXAMPLE 2 investigation delayed to support the subject of care’s scheduling choice
subject of care preference delay
subject of care agent
healthcare third party having person role with the right to take decisions on behalf of the subject of care
NOTE In ISO/TS 21298 subject of care agent is the preferred term for this concept.
subject of care proxy
patient summary repository
data repository containing summarized information for healthcare coordination and the continuity of care
summarized healthcare information repository
one of two or more terms denoting the same concept
synonym
concept system
set of concepts (3.2.1) structured according to the relations among them
system of concepts
target health condition
potential health condition representing health objectives and/or healthcare goals
EXAMPLE 1 The target condition for a worker that arrived at the Emergency Room with a broken arm is to be fully functional for work in the shortest time period. EXAMPLE 2 The target condition of a newly diagnosed diabetic adolescent boy is maintenance of his HbA1c at less than 48 mmol/mol. (HbA1c is a lab test that shows the average level of blood sugar (glucose) over the previous 3 months; it shows how well diabetes is being controlled).
NOTE Assessment of needs for healthcare activities includes identification of health objectives and/or healthcare goals. These inform decisions about relevant activities to create or update the care plan.
target condition
verbal designation of a general concept in a specific subject field
term
data value used for representing a time of day, without relating it to a particular day
time value
phenomenon that is not part of the normal course of a process but might influence it
EXAMPLES Surgical complication (anatomy and tissue reacts in an unexpected manner), electrical failure, contamination in a medicinal product, hardware failure, spontaneous recovery when the patient is awaiting therapy.
NOTE 1 to entry: An unintended event can be either expected or unexpected. NOTE 2 to entry: Activities in a process are deliberate and have a purpose. In an ideal situation purposes are always fulfilled. If an activity in whatever other process has an impact on the process currently analysed, the effect of this activity is perceived by the current process as an unintended event. Then the course of the process may deviate from the expected one. Such an exception from the desired course might prove negative or positive in comparison to the desired process outcome.
unintended event
uniprofessional healthcare plan
care plan limited to those healthcare provider activities performed by healthcare professionals having the same healthcare professional entitlement
EXAMPLE A nursing care plan.
NOTE In EN 13940-1:2007 care plan was the preferred term for this concept.
uniprofessional care plan
working hypothesis
considered condition that one or more healthcare professionals have determined to be the most consistent with the currently known observed conditions
NOTE 1 A working diagnosis is used as a label for the considered condition that one or more healthcare professionals assess as the most probable health condition and that could be concluded after further observations. The basis for such assessments is the already observed conditions. NOTE 2 Different healthcare professionals may make different interpretations and assessments of the observed conditions and thereby come to different conclusions and different working diagnosis.
working diagnosis
Expresses a partitive relationship between two concepts.