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It details core attribute categories for clinical statements, including condition and diagnosis, laterality, body site/structure, certainty level, severity, stage and grading systems, evidence level, disease duration, and diagnosis-related events such as complications and recurrence. It also covers multiple diagnosis dates, author/provider roles, clinical status, and treatment goal description with goal timeframe.","| Contact | Remarks |\n| --- | --- |\n| Same patient | Patient-centred medical record |\n| Same service provider | Healthcare professional like a doctor or nurse |\n| Same event | Consultation, home visit, hospital visit, telephone, surgery |\n| Same point in time | Date, time, duration |\n| Same organization | Healthcare facility like hospital, doctor’s office |\n| Same place | Clinic, department, outpatient clinic, medical practice |\n| Same type of stay | Outpatient, inpatient, day patient |\n\n| Attribute | Values, Remarks |\n| --- | --- |\n| Condition / Category | - Problem\u003Cbr>- Diagnosis |\n| Laterality | - left\u003Cbr>- right\u003Cbr>- bilateral |\n| Body site | - Anatomical location (arm, right lobe, etc.) |\n| Body structure | - Anatomical structure or location (as a\u003Cbr>supplement to laterality) |\n| Certainty\u003Cbr>(Verification status) | - Provisional diagnosis (Suspected diagnosis)\u003Cbr>- Confirmed diagnosis\u003Cbr>- Excluded diagnosis / Refuted diagnosis |\n| Severity | - Mild\u003Cbr>- Moderate\u003Cbr>- Severe\u003Cbr>- Life threatening\u003Cbr>- Fatal |\n| Stage | - Stage System\u003Cbr>- AJCC / UICC TNM – Stage Group\u003Cbr>- NYHA Functional Class (heart failure)\u003Cbr>- GOLD Stage (COPD)\u003Cbr>- ASA Physical Status (anaesthesia risk)\u003Cbr>- Stage Value |\n\n\n| Grade | - Grade System\u003Cbr>- Tumor-Grade (WHO / AJCC)\u003Cbr>- Gleason Score / Grade Group (prostate)\u003Cbr>- Child-Pugh Class (cirrhosis of the liver)\u003Cbr>- Grade Value |\n| --- | --- |\n| Evidence level\u003Cbr>(confirmation method) | - Based on history\u003Cbr>- Clinically confirmed\u003Cbr>- Radiologically confirmed\u003Cbr>- Histologically confirmed |\n| Evidence | - Supporting findings that substantiate the diagnosis e.g. reference to laboratory findings, CT report. |\n| Disease duration (Condition duration category) | - Acute\u003Cbr>- Chronic |\n| Diagnosis-related event (post-diagnosis event) | - Complication\u003Cbr>- Recurrence |\n| Date of diagnosis | - Date on which the diagnosis was first made(date of diagnosis YYYY, initital diagnosis YYYY, Dx YYYY) |\n| Recorded date | - Date on which the diagnosis was first recorded |\n| Onset date/time | - Timestamp onset of symptoms |\n| Asserter / Provider | - Healthcare professional who makes the diagnosis (the person or device that makes the clinical\u003Cbr>assertion) |\n| Recorder | - Healthcare professional who recorded the diagnosis the first time (the person who writes the assertion into the record and is accountable for what is saved) |\n| Author | - Healthcare professional (any actor, human or system) who creates or updates the diagnosis |\n| Resolution date | - Date of remission or cure |\n| Clinical Status | - Active (problem or diagnosis requires diagnostic or therapeutic intervention)\u003Cbr>- Inactive (problem or diagnosis is not being processed and is dormant)\u003Cbr>- Resolved |\n\n\n| Attribute | Values |\n| --- | --- |\n| Goal description | Treatment goal agreed between doctor and patient |\n| Goal timeframe | Period for achieving the target |","cbCaiqzJAvbWd9Cg","https://ap.wps.com/l/cbCaiqzJAvbWd9Cg","pdf",2611758,6,48,"English","en",105,"# Patient-Centered Record Context\n## Same patient, provider, event, time, organization, place, and stay type\n# Clinical Attribute Structure\n## Condition category, laterality, body site and structure\n## Certainty, severity, stage, and grading\n## Evidence level, disease duration, and diagnosis-related events\n# Diagnosis Lifecycle and Responsibility\n## Diagnosis date fields, onset and recorded dates\n## Asserter/provider, recorder, author, and resolution date\n## Clinical status: active, inactive, resolved\n# Treatment Planning Attributes\n## Goal description and goal timeframe","[{\"question\":\"What dimensions must match to ensure the same patient-centered medical record context?\",\"answer\":\"The record context should be aligned by same patient, service provider, event, point in time, organization, place, and type of stay (outpatient, inpatient, or day patient).\"},{\"question\":\"Which clinical attributes are required to describe a diagnosis in the information model?\",\"answer\":\"The model includes condition/category (problem/diagnosis), laterality, body site and body structure, certainty status, severity, stage, grade, evidence level, disease duration, and post-diagnosis events like complications or recurrence.\"},{\"question\":\"How does the model represent diagnosis responsibility and timeline?\",\"answer\":\"It distinguishes diagnosis-related dates (date of diagnosis, recorded date, onset date/time, resolution date) and assigns roles such as asserter/provider, recorder, and author, plus a clinical status (active, inactive, resolved).\"}]","Electronic Medical Record Requirements and Information Model - 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