July 8, 2009

Version 1.1

HITSP Clinical Document and Message Terminology Component

Submitted to:

Healthcare Information Technology Standards Panel

Submitted by:

Care Management and Health Records Domain Technical Committee

Document Change History

Version Number	Description of Change	Name of Author	Date Published
	Template Updated to V2.4	Project Team	July 31, 2008
0.0.1	Review Copy	Care Management and Health Records Domain Technical Committee	September 26, 2008
0.0.2	Review Copy	Care Management and Health Records Domain Technical Committee	December 10, 2008
1.0	Released for Implementation	Care Management and Health Records Domain Technical Committee	December 18, 2008
	Template V2.5	Project Team	June 30, 2009
1.0.1	Review Copy	Care Management and Health Records Domain Technical Committee and Data Architecture Tiger Team	June 30, 2009
1.1	Released for Implementation	Care Management and Health Records Domain Technical Committee and Data Architecture Tiger Team	July 8, 2009

Table of Contents

1.0 Introduction. 7

1.1 Overview. 7

1.2 Copyright Permissions. 7

1.3 Reference Documents. 7

1.4 Conformance. 7

1.4.1 Conformance Criteria. 7

1.4.2 Conformance Scoping, Subsetting and Options. 8

2.0 Component Definition. 9

2.1 Context Overview. 9

2.1.1 Value Set Metadata. 9

2.1.2 Code System Metadata. 11

2.1.3 Value Set Member Metadata. 12

2.1.4 Value Set Versioning. 13

2.1.5 Component Constraints. 14

2.1.6 Component Dependencies. 14

2.2 Rules For Implementing Value Sets. 24

2.2.1 General Information Value Sets. 25

2.2.2 Administration and Financial Value Sets. 32

2.2.3 Care Management and Health Record Value Sets. 36

2.3 Standards. 85

2.3.1 Regulatory Guidance. 85

2.3.2 Selected Standards. 85

2.3.3 Informative Reference Standards. 86

3.0 Appendix. 87

4.0 Document Updates. 88

4.1 December 10, 2008. 88

4.2 December 18, 2008. 90

4.3 June 30, 2009. 90

4.4 July 8, 2009. 91

Figures and Tables

Table 1-1 Reference Documents. 8

Table 2-1 Value Set Metadata. 10

Table 2-2 Code System Metadata. 12

Table 2-3 Value Set Member Metadata. 14

Table 2-4 Code Systems from American Medical Association. 15

Table 2-5 Code Systems from Accredited Standards Committee X12. 16

Table 2-6 Code Systems from Centers for Disease Control and Prevention. 16

Table 2-7 Code Systems from Centers for Disease Control and Prevention. 16

Table 2-8 Code Systems from Centers for Disease Control and Prevention. 17

Table 2-9 Code Systems from Centers for Disease Control and Prevention. 17

Table 2-10 Metadata for Code Systems from Centers for Disease Control and Prevention. 17

Table 2-11 Code Systems from Federal Information Processing Standards Publication 5-2. 18

Table 2-12 Code Systems from Food and Drug Administration. 18

Table 2-13 Code Systems from Food and Drug Administration. 18

Table 2-14 Code Systems from Health Level Seven V2. 19

Table 2-15 Metadata for Code Systems for Health Level Seven V2. 19

Table 2-16 Code Systems from Health Level Seven V3. 19

Table 2-17 Metadata for Code Systems from Health Level Seven V3. 19

Table 2-18 Code Systems from Human Genome Organization. 20

Table 2-19 Code Systems from Human Genome Variation Society. 21

Table 2-20 Code Systems from World Health Organization. 21

Table 2-21 Code Systems from International Health Terminology Standards Development Organisation. 21

Table 2-22 Code Systems from International Organization for Standardization. 22

Table 2-21 Code Systems from Internet Engineering Task Force. 22

Table 2-22 Code Systems from Regenstrief Institute, Inc. 22

Table 2-23 Code Systems from National Center for Biotechnology Information. 23

Table 2-24 Code Systems from National Cancer Institute. 23

Table 2-25 Code Systems from National Library of Medicine. 23

Table 2-26 Code Systems from National Uniform Billing Committee. 24

Table 2-14 Metadata for Code Systems from National Uniform Billing Committee. 24

Table 2-27 Code Systems from National Uniform Claim Committee. 24

Table 2-28 Code Systems from Regenstrief Institute, Inc. 25

Table 2-29 Code Systems from United States Postal Service. 25

Table 2-30 Code Systems from U.S. Veterans Health Administration. 25

Table 2-31 State Value set 26

Table 2-32 Postal Code Value Set 26

Table 2-33 Country Value Set 27

Table 2-34 Administrative Gender Value Set 28

Table 2-35 Administrative Gender Value Set Definition. 28

Table 2-36 Ethnicity Value Set 28

Table 2-37 Marital Status Value Set 29

Table 2-38 Marital Status Value Set Definition. 29

Table 2-39 Personal Relationship Value Set 30

Table 2-40 Family Relation Type Value Set 30

Table 2-41 Contact Type Value Set 31

Table 2-42 Contact Type Value Set Definition. 31

Table 2-43 Race Value Set 31

Table 2-44 Religious Affiliation Value Set 32

Table 2-45 Language Value Set 32

Table 2-46 Language Ability Value Set 33

Table 2-47 Language Ability Mode Set Definition. 33

Table 2-48 Health Insurance Type Value Set 34

Table 2-49 Health Insurance Type Value Set Definition. 34

Table 2-50 Subscriber Relationship Value Set 35

Table 2-51 Subscriber Relationship Value Set Definition. 36

Table 2-52 Financially Responsible Party Type Value Set 36

Table 2-53 Social History Type Value Set 36

Table 2-54 Social History Type Set Definition. 37

Table 2-55 Problem Value Set 37

Table 2-56 Problem Type Value Set 38

Table 2-57 Problem Type Value Set Definition. 38

Table 2-58 Diagnosis Type Value Set 39

Table 2-59 Diagnosis Type Value Set Definition. 39

Table 2-60 Diagnosis Priority Value Set 39

Table 2-61 Diagnosis Priority Value Set Definition. 40

Table 2-62 Nursing Diagnosis Value Set 40

Table 2-63 Problem Severity Value Set 40

Table 2-64 Problem Severity Value Set Definition. 41

Table 2-65 Functional Assessment Value Set 41

Table 2-66 Body Site Value Set 42

Table 2-67 Medication Fill Status Value Set 42

Table 2-68 Medication Fill Status Value Set Definition. 43

Table 2-69 Medication Product Form Value Set 43

Table 2-70 Medication Route FDA Value Set 44

Table 2-71 V2 Medication Route Value Set 44

Table 2-72 Medication Type Value Set 45

Table 2-73 Medication Type Value Set Definition. 45

Table 2-74 Medication Brand Name Value Set 45

Table 2-75 Medication Clinical Drug Name Value Set 46

Table 2-76 Medication Drug Class Value Set 46

Table 2-77 Medication Packaged Product Value Set 47

Table 2-78 Ingredient Name Value Set 47

Table 2-79 Medication Vehicle Value Set 48

Table 2-80 Allergy/Adverse Event Type Value Set 48

Table 2-81 Allergy/Adverse Event Type Value Set Definition. 49

Table 2-82 Vaccine Administered Value Set 50

Table 2-83 Vaccine Manufacturer Value Set 50

Table 2-84 No Immunization Reason Value Set 51

Table 2-85 No Immunization Reason Value Set Definition. 51

Table 2-86 Immunization Information Source Value Set 51

Table 2-87 Immunization Information Source Value Set Definition. 52

Table 2-88 Immunization Service Funding Eligibility Value Set 52

Table 2-89 Laboratory Tests Result Value Set 53

Table 2-90 Laboratory Test Result Identifier Value Set Definition. 53

Table 2-91 Laboratory Observation Value Set 66

Table 2-92 Laboratory Order Value Set 66

Table 2-93 V3 Result Normalcy Status Value Set 67

Table 2-94 V3 Result Normalcy Value Set Definition. 67

Table 2-95 V2 Result Status Code System.. 68

Table 2-96 V2 Result Status Value Set Definition. 69

Table 2-97 V3 Result Status Value Set 69

Table 2-98 V3 Result Status Value Set Definition. 70

Table 2-99 Vital Sign Result Value Set 70

Table 2-100 Vital Sign Result Value Set Definition. 71

Table 2-101 Unit of Measure Code System.. 71

Table 2-102 Procedure Value Set 71

Table 2-103 Provider Role Value Set 72

Table 2-104 Provider Role Value Set Definition. 72

Table 2-105 Provider Type Value Set 73

Table 2-106 Provider Type Value Set Definition. 73

Table 2-107 Admission Source Value Set 74

Table 2-108 Admission Type Value Set 74

Table 2-109 Encounter Type Value Set 75

Table 2-110 Discharge Disposition Value Set 75

Table 2-111 Patient Class Value Set 76

Table 2-112 V3 Patient Class Value Set Definition. 76

Table 2-113 Advance Directive Type Value Set 77

Table 2-114 Advance Directive Type Value Set Definition. 77

Table 2-115 Genetic Test Result Value Set 77

Table 2-116 Genetic Test Result Identifier Value Set Definition. 78

Table 2-117 Genetic Test Result Value Set 79

Table 2-118 Genetic Test Result Value Set Definition. 80

Table 2-119 Gene Name Value Set 82

Table 2-120 Gene Sequence Variation Value Set 82

Table 2-121 Genetic Reference Sequence Value Set 83

Table 2-122 Document Class Value Set 83

Table 2-123 Document Class Value Set Definition. 84

Table 2-124 Document Type Value Set 85

Table 2-125 Practice Setting Value Set 85

Table 2-126 Practice Setting Value Set Definition. 86

Table 2-127 Informative Reference Standards. 86