Contextual information that provides supporting details for healthcare data.

Data Element

Applicable Vocabulary Standard(s)

Diagnostic Report Date

Date and time a report containing test results or clinical interpretation was made available to providers.

Indication

Sign, symptom, or medical condition that is the reason for a care activity.

Usage note: Indication may be included with a procedure, medication, and an order.

  • SNOMED Clinical Terms® (SNOMED CT®) U.S. Edition
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
Performance Time

Time and/or date a care activity is performed.

Examples include but are not limited to vaccine and medication administration times, surgery start time, time ultrasound performed, and laboratory specimen collection time.

Reason Not Performed

Explanation or justification provided when an order or practice guideline is not carried out. 

Usage note: Should be included with a procedure, immunization, and medication.

Data Element

Report Date

Comment

Clarify the application of Healthcare Information Attritributes

It is unclear if this data class is simply an "add on" to other data classes like immunization, diagnostic imaging and laboratory? If so, that should be called out in the description  (including a full, normative list of other data class to which these attributes apply) and not just in a Usage Note in Reason Not Performed and Indication (and are these usage notes exemplars or prescriptive?)
Diagnostic Report Date and Performance Time should be aligned in name (why is one "date" and one "time") and description (one is past tense and one is present tense; one uses "date and time" while the other uses "time and/or date")
Is there a scenario where just a time, without a date, would be appropriate for performance time?
The name performance time for a laboratory instance may be confusing as it is clear that the specimen collection date/time is the relevant value, but "performance" evokes the performance of the test on a previously collected specimen

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