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:

CLINICAL INTERVENTIONS
CLINICAL INVESTIGATION RESULT ITEMS
PATIENT DIAGNOSES
PERSON PROPERTIES
PLANNED ACTIVITIES
ACTIVITY DRUGS
CARE PLANS
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

Key	Attribute Name
	CLINICAL CLASSIFICATION CODE
	CLINICAL TERMINOLOGY CODE
	CODED CLINICAL ENTRY SEQUENCE NUMBER
	DATA ABSENT REASON
	DM+D TAXONOMY CODE
	SNOMED VERSION

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