CODED CLINICAL ENTRY
An entry in an ELECTRONIC HEALTH RECORD, recorded by a CARE PROFESSIONAL, PATIENT or Patient Proxy, or other authorised PERSON, relating to ACTIVITIES for the care and treatment of a PATIENT.
Description
An entry in an ELECTRONIC HEALTH RECORD, recorded by a CARE PROFESSIONAL, PATIENT or Patient Proxy, or other authorised PERSON, relating to ACTIVITIES for the care and treatment of a PATIENT.
CODED CLINICAL ENTRIES may describe:
- ACTIVITY GROUPS
- CARE ACTIVITIES
-
any other aspect of PATIENT care and management.
A CODED CLINICAL ENTRY in an ELECTRONIC HEALTH RECORD should include the recording of relevant CLINICAL TERMINOLOGY CODES and/or CLINICAL CLASSIFICATION CODES. Where information to complete the CODED CLINICAL ENTRY is missing, a DATA ABSENT REASON should be recorded.
Attributes
Relationships
Each CODED CLINICAL ENTRY
Key | Relationship | Class |
---|---|---|
may be a classification for one or more | ACTIVITY DRUG | |
may be a classification for one or more | CLINICAL INTERVENTION | |
may be a classification for one or more | CLINICAL INVESTIGATION RESULT ITEM | |
must be an entry in one and only one | ELECTRONIC HEALTH RECORD | |
may be a classification for one or more | PATIENT DIAGNOSIS | |
may be a classification for one or more | PERSON PROPERTY | |
may be a classification for one or more | PLANNED ACTIVITY |
Where Used
Type | Link | How used |
---|---|---|
NHS Business Definition | ABO System | references in description CODED CLINICAL ENTRY |
Attribute | CLINICAL CLASSIFICATION CODE | references in description CODED CLINICAL ENTRY |
Attribute | CLINICAL TERMINOLOGY CODE | references in description CODED CLINICAL ENTRY |
Class | CODED CLINICAL ENTRY | references in description CODED CLINICAL ENTRY |
Attribute | CODED CLINICAL ENTRY SEQUENCE NUMBER | references in description CODED CLINICAL ENTRY |
Data Element | CODED FINDING (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Attribute | DATA ABSENT REASON | references in description CODED CLINICAL ENTRY |
Data Element | DATA ABSENT REASON (FHIR R4) | references in description CODED CLINICAL ENTRY |
Data Element | DIAGNOSIS (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Attribute | DIAGNOSIS SCHEME IN USE | references in description CODED CLINICAL ENTRY |
Data Element | DM+D CODE | references in description CODED CLINICAL ENTRY |
Attribute | FINDING SCHEME IN USE | references in description CODED CLINICAL ENTRY |
Data Element | ICD-10 CODE | references in description CODED CLINICAL ENTRY |
Data Element | ICD-O CODE | references in description CODED CLINICAL ENTRY |
NHS Business Definition | Intended Patient Procedure | references in description CODED CLINICAL ENTRY |
Attribute | LOCAL TREATMENT CATEGORY CODE | references in description CODED CLINICAL ENTRY |
Attribute | LOCAL TREATMENT CODE | references in description CODED CLINICAL ENTRY |
Data Element | LONG TERM PHYSICAL HEALTH CONDITION (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Data Element | NICIP CODE | references in description CODED CLINICAL ENTRY |
Data Element | OPCS-4 CODE | references in description CODED CLINICAL ENTRY |
Class | OPERATING THEATRE | references in description CODED CLINICAL ENTRY |
Data Element | PRESENTING COMPLAINT (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Data Element | PREVIOUS DIAGNOSIS (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Data Element | PRIMARY DIAGNOSIS (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Attribute | PROCEDURE SCHEME IN USE | references in description CODED CLINICAL ENTRY |
Data Element | PROVISIONAL DIAGNOSIS (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Data Element | READ CODE | references in description CODED CLINICAL ENTRY |
NHS Business Definition | Rh System | references in description CODED CLINICAL ENTRY |
Data Element | SECONDARY DIAGNOSIS (CODED CLINICAL ENTRY) | references in description CODED CLINICAL ENTRY |
Attribute | SITUATION SCHEME IN USE | references in description CODED CLINICAL ENTRY |
Data Element | SNOMED CT CODE | references in description CODED CLINICAL ENTRY |
Also Known As
This class is also known by these names:
Context | Alias |
---|---|
Plural | CODED CLINICAL ENTRIES |