A text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.

The type, kind, or class of this item.

Code representing the sense in which the statement is interpreted, for example, the degree of presence in a PresenceStatement.

A description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

The technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.

A clinical interpretation of a finding (applies to both assertions and observation).

A file that contains audio, video, image, or similar content.

The person this entry belongs to.

A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.

If the problem or condition existed before the current episode of care.

The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.

The time or time period that the finding addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).

Provenance information specific to the signing of the clinical statement.

The concept representing the finding or action that is the topic of the statement.

For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the ‘question’ or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic of the action or the finding.

The time at which a condition or condition was first identified in a healthcare context.

A human-readable identifier for the lesion; e.g., a letter or integer.

A specialization of condition cause, specific to the causes of injuries (or not having injury in the wound absent context).

A type code describing the wound or skin injury. Differentiating pressure ulcers and other types of wounds is important for an accurate count of their number and for identifying appropriate wound treatment. The values will be used for documenting and retrieving data regarding the number and types of wounds present.