Adverse Event Assessment CMET Description

Abnormality Assessment CMET RMIM & Data Dictionary

HL7 Project ID: 178

Laboratory Test Result Abnormality Assessment

CMET RMIM Data Dictionary

September 20, 2007

Version 0.4

HL7 Project ID: 178 | Laboratory Test Result Abnormality Assessment Messaging Specification 3 of 3

Abnormality Assessment CMET RMIM & Data Dictionary

The Abnormality Assessment CMET is used to communicate data about initial, first-level assessments of laboratory test results for indications of the presence and severity of an abnormal condition.

AbnormalityAssessment

The process of evaluating a clinical finding, including a laboratory test result, to detect the presence and severity of an abnormal condition, and to assign the corresponding descriptive terminology.

Attributes

  ClassCode: a code that identifies Observation as the type of act.

  MoodCode: a code that identifies Event as the type of mood.

  Code: a code that specifies the type of observation as Adverse Reaction.

  StatusCode: a coded value that specifies the action taken (aborted/invalid; cancelled/not assessed; completed/assessed and inconclusive) with respect to the assessment for abnormality.

  ActivityTime: the date and time at which the automated assessment for abnormality was performed.

  UncertaintyCode: a code that specifying whether the grade assignment has been asserted to be uncertain in any way.

  Value: specifies the code system and coded value for the abnormality.

  MethodCode: a code that provides additional detail about the means used to arrive at the assessment result.

AssessmentException

This class represents one of two possible observation outcomes of an AbnormalityAssessment. A message provided to indicate that an assessment could not be executed or completed and to identify the reason for the failure.

Attribute

  ClassCode: a code that identifies Observation as the type of act

  MoodCode: a code that identifies Event as the type of mood

  Code: a code that specifies the type of observation as Assertion

  Value: a coded value and description specifying the reason an assessment could not be executed or completed and is provided with the assessment status code of aborted/invalid and cancelled/not assessed.

AbnormalityGrade

This class represents one of two possible observation outcomes of the AbnormalityAssessment. The severity of the abnormality is based on a specified assessment scale.

Attribute

  ClassCode: a code that identifies Observation as the type of act

  MoodCode: a code that identifies Event as the type of mood

  Code: a code that identifies the type of observation as Severity

  Value: a coded value that represents the grade/level of severity associated with an assessed abnormality (grade 0 – 5).

GradeAnnotation

Additional information provided about a grade that must be considered in order to determine the final grade.

Attribute

  ClassCode: a code that identifies Observation as the type of act

  MoodCode: a code that identifies Event as the type of mood

  Code: a code that specifies the type of observation as Assertion

  Value: text that provides additional information about the severity grade, which must be considered before determining the final grade.

HL7 Project ID: 178 | Laboratory Test Result Abnormality Assessment Messaging Specification 3 of 3