hl7 v2 data requirements and pre-work - wvhin – west ... · web viewhl7 v2 data requirements and...

HL7 v2 Data Requirements and Pre-workHospital/Provider Name, ST

Participant Pre-workAudience:The Executive Sponsor, Project Manager, End User, and EHR Interface Engineer should collaborate to complete the Pre-work and Coded Values sections of this document.

Pre-work Instructions:Please complete the questions on this page regarding system information, historical data backload, and sensitive health data. Also, please complete the Coded Values section at the end of this document.

System Information:

Please list all unique source system vendor names and versions:

Are patient IDs unique across all source systems?

Are visit IDs unique across all source systems?

Do your systems support patient merges (ex. ADT-A18, ADT-A34)?

Do your systems support account merges (ex. ADT-A18, ADT-A34)?

Will you be implementing Trusted Application Integration?

Historical Data Backload:

Will you be providing a historical data backload?

If yes, please specify timeframe (2 to 3 years):

Please specify format of data backload (i.e. HL7, flat file):

Sensitive Health Data:

The WVHIN system has the capability to flag certain codes and criteria as sensitive. Visibility will be based on user-access policies applied at the end-user level. The WVHIN’s policy on Patient Consent – Sensitive Health Information can be found here.

Following the kick-off call, the Truven Health project manager assigned to your on-boarding project will provide technical guidelines for your security officer to review and acknowledge.

December 2014 – v1 Page | 1

http://www.wvhin.org/App_Media/assets/doc/wvhin/policies/Sensitive_Health_Information_Version_06-02-13_(C2613076).pdf

HL7 v2 Data Requirements – WVHINHL7 v2 Data Requirements by Segment Specification............................................................4

1) MSH Segment Specification (Message Header) - Required................................42) PID Segment Specification (Patient Identification) - Required.............................4

3) NK1 Segment Specification (Next of Kin) - Optional............................................54) PV1 Segment Specification (Patient Visit) - Required..........................................5

5) DG1 Segment Specification (Patient Diagnoses) - Required...............................66) PR1 Segment Specification (Procedures Segment) - Desired.............................7

7) IN1/IN2 Segment Specification (Insurance Segment) - Desired..........................78) Orders - Required.................................................................................................8

9) Discrete Observations - Required........................................................................910) Observation Groups - Required...........................................................................9

11) Observation Results - Required.........................................................................1012) Medication Orders - Required............................................................................11

13) Medication Components - Required...................................................................1214) Medications Administered - Desired...................................................................13

15) Report Text - Optional........................................................................................1416) Problems - Required..........................................................................................14

17) Allergies - Required............................................................................................1418) Specimens - Optional.........................................................................................15

Coded Values.....................................................................................................................161) Facility Codes.....................................................................................................16

2) Allergen Type Code............................................................................................163) Allergen Severity Code.......................................................................................16

4) Observations Result Status Code......................................................................165) Abnormal Flag Code..........................................................................................17

6) Diagnosis Type Code.........................................................................................187) Diagnosis Coding System Code.........................................................................18

8) Diagnosis Priority...............................................................................................189) Present on Admission Indicator Code................................................................19

10) Procedure Coding System Type Code...............................................................1911) Problem Action Code.........................................................................................19

12) Patient Class Code.............................................................................................2013) Admission Type Code........................................................................................20

14) Admission Source Code.....................................................................................2015) Race...................................................................................................................21


16) Ethnicity..............................................................................................................21

17) Gender...............................................................................................................2118) Plan Type Code..................................................................................................22

19) Discharge Disposition Code...............................................................................2320) Marital Status Code............................................................................................25


HL7 v2 Data Requirements by Segment SpecificationPlease review the Default HL7 Locations, Field Name, and Standard Description as it applies to your healthcare facility or healthcare system.

Bolded fields contain Coded Values. Please refer to the Coded Values section at the end of this document to specify Hospital/Clinic Values.

1) MSH Segment Specification (Message Header) - RequiredDefault

HL7 Location Field Name Standard Description MSH.3 Sending Application Name of application that sent HL7 messageMSH.4 Sending Facility Name of healthcare facility that sent HL7 messageMSH.9.1 Message Code HL7 message type, (e.g., ADT, ORU, etc.)MSH.9.2 Event Type Code HL7 event type (e.g., A01, A08, etc.)MSH.10 Message Control Number Message Control ID assigned by sending application

2) PID Segment Specification (Patient Identification) - RequiredDefault

HL7 Location Field Name Standard Description

PID.3.1 Local Patient Number Identifier used by healthcare facility to uniquely identify a patient. Also referred to as Medical Record Number.

PID.4.1 Unique Patient NumberOptional identifier used to uniquely identify a patient across facilities within a hospital system. Also referred to as the Unique Patient Identifier.

PID.5.1 Last Name Last name of patientPID.5.2 First Name First name of patientPID.5.3 Middle Name Middle name (or initial) of patientPID.7 Birth Date/Time Patient's date of birthPID.8 Gender Code Patient's genderPID.10 Race Code Patient's racePID.11.1 Street Address 1 First line of street address of patient's mailing addressPID.11.2 Street Address 2 Second line of street address of patient's mailing addressPID.11.3 Address City City of patient's mailing addressPID.11.4 Address State State of patient's mailing addressPID.11.5 Address Zip Zip codePID.11.6 Address Country Country of patient's mailing addressPID.12 Address County County of patient's mailing addressPID.13 Home Phone Patient's home phone numberPID.14 Business Phone Patient's business phone numberPID.15.2 Primary Language Primary language spoken by patientPID.16 Marital Status Code Patient's marital statusPID.17 Religion Code Patient's religion


Default HL7

Location Field Name Standard Description

PID.18 Visit NumberUnique number assigned to each patient visit across facilities and systems. Also referred to as Patient Account Number or Episode of Care ID. Must be present in PID.18 or PV1.19.

PID.19 SSN Patient’s Social Security NumberPID.22 Ethnic Group Code Patient's ethnic group code

PID.30 Death Indicator Code Field indicates whether he patient is deceased. Valid values are Y and N.

MRG.1.1 Prior Patient NumberUsed only in patient merge messages, this field contains prior patient identifier. Also referred to as the Med Prior Patient Identifier.

3) NK1 Segment Specification (Next of Kin) - OptionalDefault

HL7 Location Field Name Standard Description NK1.2.1 Last Name Last name of patient’s next of kinNK1.2.2 First Name First name of patient’s next of kinNK1.2.3 Middle Name Middle name (or initial) of patient’s next of kinNK1.3 Relationship Relationship of next of kin to patientNK1.4.1 Street Address 1 First line of street address of next of kin's mailing addressNK1.4.2 Street Address 2 Second line of street address of next of kin's mailing addressNK1.4.3 Address City City of next of kin's mailing addressNK1.4.4 Address State State of next of kin's mailing addressNK1.4.5 Address Zip Zip code of next of kin's mailing addressNK1.4.6 Address Country Country of next of kin's mailing addressNK1.4.9 Address County Code County of next of kin's mailing addressNK1.5 Home Phone Next of kin's home phone numberNK1.6 Business Phone Next of kin's business phone number

4) PV1 Segment Specification (Patient Visit) - RequiredDefault


PV1.2 Patient Class Code Used to categorize patients (inpatient, outpatient, emergency, obstetrics, etc)

PV1.3.1 Point of Care Description of patient's assigned location, or location to which patient is being moved. Also known as ward or unit.

PV1.3.2 Room Patient's assigned room, or the room to which patient is being moved

PV1.3.3 Bed Patient's assigned bed, or the bed to which patient is being moved

PV1.4 Admission Type Code Circumstances under which patient was or will be admitted


Default HL7

Location Field Name Standard Description PV1.7.1 Attending DoctorPV1.8.1 Referring DoctorPV1.9.1 Consulting Doctor

PV1.10 Hospital Service Treatment or type of surgery that patient is scheduled to receive (e.g., cardiac, medical, pulmonary, etc)

PV1.14 Admission Source Code Indicates where patient was admittedPV1.16 VIP Indicator Site-specific value indicating if the patient is a VIPPV1.17.1 Admitting DoctorPV1.18 Patient Type Site-specific values that identify patient type

PV1.19 Visit NumberUnique number assigned to each patient visit across facilities and systems. Also referred to as Patient Account Number or Episode of Care ID. Must be present in PID.18 or PV1.19.

PV1.20.1 Financial Class Site-specific values that identify financial class(es) assigned to patient for purpose of identifying sources of reimbursement

PV1.20.2 Financial Class Effective Date/Time Effective date of Financial Class

PV1.36 Discharge Disposition Code Contains disposition of patient at time of discharge

PV1.37.1 Discharge To Location Healthcare facility to which patient was discharged

PV1.37.2 Discharge To Location Date/Time Discharge date associated with Discharged To Location Code

PV1.44 Admit Date/Time Admit date/timePV1.45 Discharge Date/Time Discharge date/timePV1.52.1 Other Healthcare ProviderPV2.3 Reason for Visit Short description of the reason for patient visit

PV2.38 Mode of Arrival Site-specific code indicating how patient was brought to healthcare facility (i.e. ambulance, car, etc)

PV2.40 Admission Level of Care Indicates acuity level assigned to patient at time of admission (e.g., acute, chronic, critical)

PD1.4.1 Patient Primary Care Provider

MRG.3 Prior Visit Number Used only in visit merge messages, this field contains prior visit identifier


5) DG1 Segment Specification (Patient Diagnoses) - RequiredDefault


DG1.3.1 Diagnosis CodeUniquely identifies a particular diagnosis. This element may conform to some external, standard coding system or it may be local code or free text

DG1.3.2 Diagnosis Description Description supplied by hospital for Diagnosis Code

DG1.3.3 Diagnosis Coding System Code

Coding system used in Diagnosis Code field (e.g., ICD9, ICD10 or Snomed CT)

DG1.5 Diagnosis Date/Time Date/time that diagnosis was determined

DG1.6 Diagnosis Type Code Identifies type of diagnosis being sent (i.e., admitting, working or final)

DG1.15 Diagnosis Priority Identifies significance or priority of diagnosis code

DG1.26 Present on Admission Indicator Code

Present on Admission indicator for this particular diagnosis. Reimbursement formulas for some states and Medicare have mandated that each diagnosis code be flagged as to whether it was present on admission or not.

6) PR1 Segment Specification (Procedures Segment) - DesiredDefault


PR1.3.1 Procedure CodeUniquely identifies a particular procedure. This element may conform to some external, standard coding system or it may be local code or free text.

PR1.3.2 Procedure Description Description supplied by hospital for Procedure Code

PR1.3.3 Procedure Coding System Type Code

Coding system used in Procedure Code field (e.g., ICD9 or CPT)

PR1.14 Procedure Priority Number that identifies significance or priority of procedure code

PR1.16 Procedure Code Modifier Procedure code modifier to Procedure Code, when applicable

7) IN1/IN2 Segment Specification (Insurance Segment) - DesiredDefault

HL7 Location Field Name Standard Description IN1.2.1 Plan Number Site-specific identifier for insurance planIN1.2.2 Plan Name Name of insurance planIN1.3 Company Number Site-specific identifier for insurance companyIN1.36 Insured's Policy Number Individual policy number of insured to identify patient's planIN1.4 Company Name Name of insurance companyIN1.45 Verification Status Status of patient's relationship with insurance carrierIN1.5.1 Company Street Street of insurance company's mailing addressIN1.5.3 Company City City of insurance company's mailing address


Default HL7

Location Field Name Standard Description IN1.5.4 Company State State of insurance company's mailing addressIN1.5.5 Company Zip Zip code of insurance company's mailing addressIN1.5.6 Company Country Country of insurance company's mailing addressIN1.7 Company Phone Phone number of insurance companyIN1.8 Group Number Group number of insured's insuranceIN1.9 Group Name Group name of insured's insuranceIN1.11 Employer Name Name of employer that provides employee's insuranceIN1.15 Plan Type Code Identifies type of health insurance plan

IN2.6 Medicare Health Insurance Card Number

Medicare Health Insurance Card Number (HIN), as defined by CMS or other regulatory agencies.

8) Orders - RequiredThe Orders section contains fields that describe non-medication orders. An order is a request for material or services, usually for a specific patient. Examples include orders for clinical observations (e.g., vitals, I&Os) from the nursing service, tests in the laboratory, food from dietary, films from radiology, etc. There may be multiple orders per message.

Default HL7

Location Field Name Standard Description ORC.1 Order Control Code Describes function of order segment within message

ORC.3.1 Filler Order Number Identification number that is assigned by application that filled order

ORC.2.1 Placer Order Number Identification number that is assigned by application that placed order

ORC.3.1 Unique Order NumberUnique identification number for medication order. This may be Filler Order Number, Placer Order Number, or concatenation of the two

OBR.4.1 Service CodeUniquely identifies particular type of order (e.g., an order for a specific lab test. This element may conform to some external, standard coding system or it may be local code.

OBR.4.3 Service Coding System Coding system used in Service CodeOBR.4.2 Service Name Description supplied by hospital for Service Code

ORC.7.1 QuantityNumeric quantity of service that should be provided at each service interval. For example, if two blood cultures are to be obtained every 4 hours quantity would be "2".

ORC.7.2 Interval Interval at which order should be performed (e.g., "daily")ORC.7.3 Duration Duration of order (e.g., "for 3 days")ORC.7.4 Start Date/Time Explicit start date and time for medication orderOBR.7.5 End Date/Time Explicit end date and time for medication orderORC.7.6 Priority Priority of request (e.g., stat or routine)

ORC.7.7 Condition Free text field that describes condition under which service should be performed. Also known as PRN.

ORC.9 Transaction Date/Time Date and time of event that initiated current transaction, as defined in Order Control Code


Default HL7


ORC.16 Order Control Code Reason

Explanation of reason for order event described by Order Control Code. This field may be either coded or free text form.

MSH.3 Category Type of order (e.g., lab order or microbiology order)NTE.3 Note Any free text notes associated with lab order

OBR.16.1 Caregiver Number Healthcare facility's identification code for provider who ordered material or service

OBR.16.2 Last Name Ordering provider's last nameOBR.16.3 First Name Ordering provider's first name

9) Discrete Observations - Required The Discrete Observations section contains fields that describe observations related to an order. These observations may include unstructured notes such as the reason for exam, or more structured comments related to a specific type of order. There may be multiple order observations per order.

Default HL7

Location Field Name Standard Description OBX.1 Sequence Number Sequence number of this observation within order message

ORC.3.1 Order Unique Order Number

Unique identification number for order, repeated from Orders Unique Order Number field.

OBX.3.1 Observation Type CodeUniquely identifies a particular type of observation within order message. This element may confirm to some external, standard coding system or it may be local code or free text.

OBX.3.2 Observation Type Name Description supplied by hospital for Observation Type Code

OBX.3.3 Observation Type Coding System Coding system used in Observation Type Code

OBX.5 Observation Value Value provided in this observation (e.g., textual description of reason for a radiology exam)

NTE.3 Note Any free text notes associated with order observation


10)Observation Groups - RequiredThe Observation Groups section contains identifiers and other fields related to a group of observations, i.e., lab, vitals or microbiology results. There may be multiple observation groups per message.

Default HL7

Location Field Name Standard Description OBR.1 Sequence Number Sequence number of this observation within message

OBR.2.1 Placer Order Number Identification number assigned by application that placed medication order

OBR.3.1 Filler Order Number Identification number assigned by application that filled lab order

OBR.3.1 Unique Order Number Unique identification number for order. May be Filler Order Number, Placer Order Number, or concatenation of the two

OBR.4.1 Service CodeUniquely identifies particular type of observation. This element may conform to some external, standard coding system or may be a local code

OBR.4.2 Service Name Description supplied by hospital for Observation Type CodeOBR.4.3 Service Coding System Coding system used in Service Code

OBR.7.1 Observation Date/Time

In the case of observations taken directly from a subject, this is actual date and time observation was obtained. In the case of specimen-associated study, this represents date and time specimen was collected or obtained

OBR.16.1 Caregiver Number Healthcare facility's identification number for provider who ordered observation

OBR.16.2 Last Name Ordering provider's last nameOBR.16.3 First Name Ordering provider's first name

OBR.22 Observation Report Status Date/Time

Date and time results are composed into report andreleased, or that a status, or defined in Order Status, is entered or changed

OBR.25 Result Status Code Status of results for this order

NTE.3 Note Any free text notes associated with the vital signs observation results

11)Observation Results - RequiredThe Observation Results section contains information about the results of an observation such as a lab test or vital sign. There may be multiple observation results per message.

Default HL7

Location Field Name Standard Description OBX.1 Sequence Number Sequence number of lab result (within message)

OBR.3.1 Observation Group Unique Order Number

Unique identification number for order, repeated from Observation Group Unique Order Number

OBX.3.1 Observation Type CodeUniquely identifies particular type of observation.This element may confirm to some external, standard coding system or may be local code or free text


Default HL7

Location Field Name Standard Description OBX.3.2 Observation Type Name Description supplied by hospital for Observation Type Code

OBX.3.3 Observation Type Coding System Code Coding system used in Observation Type Code

OBX.5 Observation Value Hospital-supplied value for observationOBX.6 Observation Units Hospital-supplied unit of measure for Observation ValueOBX.7 Reference Range Normal range for specific numeric laboratory result valueOBX.8 Abnormal Flag Code Code indicating normalcy status of resultOBX.11 Result Status Code Status of results for this order

OBX.14 Observation Date/Time

In the case of observations taken directly from a subject, this is actual date and time observation was obtained. In the case of specimen-associated study, this represents date and time specimen was collected or obtained

NTE.3 Note Any free text notes associated with lab or vitals observation result

12)Medication Orders - RequiredThe Medication Orders section contains fields that describe a medication order. There may be multiple medication orders per message.

PLEASE NOTE: RXO (non-encoded order) segments are supported in addition to RXE segments and RXR segments.

Default HL7


ORC.1 Order Control Code Describes function of order segment within message (e.g. "NW" (new) or "CA" (cancel order)

ORC.2 Placer Order Number Identification number assigned by application that placed medication order

ORC.3 Filler Order Number Identification number assigned by application that filled medication order

ORC.3 Unique Order NumberUnique identification number for medication order. This may be Filler Order Number, Placer Order Number, or a concatenation of the two.

ORC.5 Order Status Code Describes status of order (e.g., completed, discontinued, etc.)

ORC.9 Transaction Date/Time Date and time of event that initiated current transaction, as defined in Order Control Code

ORC.12.1 Caregiver Number Healthcare facility's identification number for provider who ordered medication

ORC.12.2 Last Name Ordering provider's last nameORC.12.3 First Name Ordering provider's first name

RXE.1.1 Quantity Numeric quantity of medication that should be provided at each service interval

RXE.1.2 Interval Interval at which medication should be provided (e.g., “every 4 hours”)


Default HL7

Location Field Name Standard Description RXE.1.3 Duration Duration of medication order (e.g., "for 3 days")RXE.1.4 Start Date/Time Explicit start date and time for medication orderRXE.1.5 End Date/Time Explicit end date and time for medication orderRXE.1.6 Priority Priority of request (e.g., stat or routine)

RXE.1.7 Condition Condition on which medication should be given (e.g., "as needed for pain". Also known as PRN)

RXE.3 Minimum Dose

Ordered amount as encoded by pharmacy or treatment supplier. In variable dose order, this is minimum order amount. In non-varying dose order, this is exact amount of order

RXE.4 Maximum Dose In variable dose order, this is maximum ordered amount. In non-varying dose, field not used

RXE.5.1 Dose Units Units for Minimum Dose and Maximum Dose fields

RXE.7.2 Provider Administration Instructions

Ordering provider's instructions to patient or provider administering drug

RXE.21 Supplier Administration Instructions

Pharmacy or treatment supplier's provider-generated special instructions to provider dispensing/administering order

RXE.23 Dose Rate Amount Rate at which substance should be administeredRXE.24 Dose Rate Units Units for Dose Rate AmountRXR.1.1 Route Site-specific route of administration from medication order

NTE.3 Note Any additional free text notes associated with medication ordered

13)Medication Components - RequiredThe Medication Components section contains fields that describe the components of an ordered medication. There should always be at least one component per medication, and there can be multiple components, e.g. for IV medications. Note that medication component information may be provided in the RXE and/or the RXC segments of an HL7 message.

PLEASE NOTE: RXO (non-encoded order) segments are supported in addition to RXE segments and RXC segments.

Default HL7

Location Field Name Standard Description RXE.2.1 orRXC.2.1

Component CodeUniquely identifies medical substance or treatment ordered. This element may confirm to some external, standard coding system or it may be a local code or free text

RXE.2.2 orRXC.2.2

Component Name Description supplied by hospital for Component Code

RXE.2.3 orRXC.2.3

Component Coding System Coding system used in Component Code

RXE.10 or

Component Amount Amount to be dispensed, as encoded by pharmacy or treatment supplier


Default HL7

Location Field Name Standard Description RXC.3RXE.11 orRXC.4

Component Units Contains units for Component Amount as encoded by pharmacy or treatment supplier

RXE.31.1 orRXC.7.1

Supplementary Code

Field accommodates identification of any additional codes supplied in HL7 message that might be associated with pharmaceutical substance. Common codes include Generic Product Identifier (GPI), Generic Coe Number_Sequence Number (GCN_SEQNO), and National Drug Code (NDC).

RXE.31.2 orRXC.7.2

Supplementary Name Description supplied by hospital for Supplementary Code

RXE.31.3 orRXC.7.3

Supplementary Coding System Coding system used in Supplementary Code

14) Medications Administered - DesiredThe Medications Administered section contains fields that describe the administration of a medication order. There may be multiple Medications Administered per order (one for each administration).

Default HL7


RXA.2 Administration CounterStarts with ‘1’ first time that medication/treatment is administered for this order, and increments by one with each additional administration of medication/treatment

RXA.3 Administration Start Date/Time Date and time administration of medication was started

RXA.4 Administration End Date/Time Date and time administration of medication was ended

RXA.5.1 Medication Code Site-specific identifier of medical substance/treatmentadministered

RXA.5.2 Medication Name Description supplied by hospital for Medication Code

RXA.5.3 Medication Coding System Coding system used in Medication Code

RXA.6 Administered Amount Contains amount administered

RXA.7 Administered Units Must be in simple units that reflect actual quantity of substance administered. Does not include compound units

RXA.9.2 Administration Notes Notes from provider administering medication/treatment

RXA.18 Refusal ReasonReason patient refused medical substance/treatment. Any entry in field indicates patient did not take substance

RXA.20 Completion Status Site-specific status of treatment administration event (i.e., completed, refused, not administered)

RXR.1.1 Route Site-specific code for route by which medication was administered


Default HL7

Location Field Name Standard Description NTE.3 Note Any free text notes associated with medication administered

15)Report Text - OptionalThe Report Text section contains fields from a message with unstructured text such as nursing notes, pathology reports, radiology reports, or transcribed reports. There may be multiple report text sections per message.

Default HL7


OBR.3.1 Observation Group Unique Order Number

Unique identification number for report, repeated from Observation Group Unique Order Number

OBR.4.2 Report Text Header Brief text that describes report (e.g., "CHEST PA LAT")

OBX.5 Report Text BodyBody of text report. Note that if message contains multiple result segments, OBX.5 values from all OBXs for specific OBR will be concatenated together, with /n as delimiter

NTE.3 Note Any free text notes associated with report text component

16)Problems - RequiredThe Problem Reports section contains fields that are used to describe the patient's acute and chronic problems, as tracked in a longitudinal patient record. Problems may span multiple visits or encounters.

Default HL7

Location Field Name Standard Description PRB.1 Action Code Code that describes intent of message

PRB.2 Action Date/Time Date/time that operation represented by action code was performed

PRB.3.1 Problem CodeIdentifies type of problem, from institution's master list of problems. Element may conform to some external, standard coding system or it may be local code or free text

PRB.3.2 Problem Description Description supplied by hospital for Problem Code

PRB.3.3 Problem Coding System Code Coding system used in Problem Code field

PRB.4.1 Problem Number Identifier assigned by initiating system to instance of problem

PRB.7 Problem Established Date/Time

Date/time when corresponding problem initially identified by caregiver

PRB.9 Actual Problem Resolution Date/Time Date/time that problem actually resolved

PRB.12 Problem Persistence Perseverance of problem (e.g., acute, chronic, etc.)

PRB.14.1 Problem Life Cycle Status Current status of problem (e.g., active, active-improving, active-stable, active worsening, inactive, resolved, etc.)

PRB.16 Problem Onset Date/Time Date/time when problem began


Default HL7

Location Field Name Standard Description NTE.3 Note Any free text notes associated with problem

17)Allergies - RequiredThe Allergies section contains fields that describe the patient's allergies. There may be multiple allergies per patient. Note that allergy information may be provided in either the AL1 or IAM segment of an HL7 message.

Default HL7

Location Field Name Standard Description AL1.2 orIAM.2 Allergen Type Code General allergy category (drug, food, pollen, etc.)

AL1.3.1 orIAM.3.1

Allergen CodeUniquely identifies particular allergen. Element may conform to some external, standard coding system or it may be local code or free text

AL1.3.2 orIAM.3.2

Allergen Description Description supplied by hospital for Allergen Code

AL1.3.3 orIAM.3.3

Allergen Coding System Code Coding system used in Allergen Code field

AL1.4 orIAM.4 Allergy Severity Site-specific value that indicates general severity of

allergy (e.g. mild, moderate, severe, etc.)AL1.5 orIAM.5 Allergy Reaction Site-specific value that indicates specific allergic reaction

documented (i.e., itching, nausea, etc.)AL1.6 orIAM.11 Onset Date/Time Date and time allergy was identified

IAM.6.1 Allergy Action CodeDefines status of record, (e.g., add/insert, update, delete). Allows hospitals to send allergy messages that delete or update previously sent allergy messages.


18)Specimens - OptionalThe Specimens section contains fields that describe the specimen that was tested as part of a microbiology test or lab order. There may be multiple specimens per message. Completion of this section is not required if specimens data will not be sent in HL7 messages.

Default HL7


SPM.2 Specimen Number Unique identifier for specimen, as referenced by placer application, filler application, or both

SPM.4.1 Specimen Type Code Site-specific code for specimen typeSPM.4.2 Specimen Type Name of specimen type

SPM.4.3 Specimen Type Coding System Coding system used in Specimen Type Code field

SPM.8.1 Specimen Source Site Code Code describing body site for specimen collection

SPM.8.2 Specimen Source Site Name of body site for specimen collection

SPM.8.3 Specimen Source Site Coding System Coding system used in Specimen Source Site Code field


Coded ValuesPlease provide your Hospital/Clinic Codes in each of the tables below if different from the Standard Code listed for each description.

1) Facility CodesPlease enter all facility codes that will be sent in MSH.4 and corresponding facility name (separate each facility code and facility name with a carriage return).

Facility Code(s) Facility Name(s)

2) Allergen Type Code

Standard DescriptionStandard

CodeHospital/Clinic Code (if different from Standard) Notes

Animal allergy AADrug allergy DAEnvironmental allergy EAFood allergy FAPollen allergy LAMiscellaneous allergy MAMiscellaneous contraindication MCPlant allergy PA

3) Allergen Severity Code



Mild MIModerate MOSevere SVUnknown U

4) Observations Result Status Code



Record coming over is a correction and thus replaces a final result

C

Deletes the OBX record DFinal results; Can only be changed with a corrected result.

F

Specimen in lab; results pending INot asked; used to affirmatively document that the observation

N




identified in the OBX was not sought when the universal service ID in OBR-4 implies that it would be sought.Order detail description only (no result)

O

Preliminary results PResults entered -- not verified RPartial results. Deprecated. Retained only for backward compatibility as of V2.6.

S

Results status change to final without retransmitting results already sent as 'preliminary.' E.g., radiology changes status from preliminary to final

U

Post original as wrong, e.g., transmitted for wrong patient

W

Results cannot be obtained for this observation

X

5) Abnormal Flag Code



Below absolute low-off instrument scale <Above absolute high-off instrument scale >Abnormal (applies to non-numeric results) AVery abnormal (applies to non-numeric units, analogous to panic limits for numeric units)

AA

Anti-complementary substances present ACBetter-use when direction not relevant BSignificant change down DDetected DETAbove high normal HAbove upper panic limits HHIntermediate. Indicates for microbiology susceptibilities only.

I

Indeterminate INDBelow low normal LBelow lower panic limits LLModerately susceptible. Indicates for microbiology susceptibilities only.

MS




Normal (applies to non-numeric results) NNot Detected NDNegative NEGNon-reactive NRPositive POSQuality Control Failure QCFResistant. Indicates for microbiology susceptibilities only.

R

Reactive RRSusceptible. Indicates for microbiology susceptibilities only.

S

Cytotoxic substance present TOXSignificant change up UVery susceptible. Indicates for microbiology susceptibilities only.

VS

Worse-use when direction not relevant WWeakly reactive WR

6) Diagnosis Type CodeStandard

DescriptionStandard


Admitting AFinal FWorking W

7) Diagnosis Coding System Code



ICD-9 I9ICD-10 I10Snomed Clinical Terms SCT

8) Diagnosis Priority



Not included in diagnosis ranking 0

The primary diagnosis 1First other diagnosis 2Second other diagnosis 3


9) Present on Admission Indicator Code



Yes YNo NExempt EUnknown UNot Applicable W

10)Procedure Coding System Type Code



CPT CPTICD-9 I9ICD-10 I10HCPCS HCPCSSnomed Clinical Terms SCT

11)Problem Action Code



Add ADCorrect CODelete DELink LIUnchange UCUnlink UNUpdate UP


12)Patient Class Code


CodeHospital/Clinic Code

(if different from Standard) NotesInpatient IOutpatient OEmergency EObstetrics BPre-admit PRecurring RUnknown UNot Applicable N

13)Admission Type Code



(if different from Standard) NotesElective CEmergency EUrgent UAccident ALabor and Delivery LNewborn NRoutine R

14)Admission Source Code



(if different from Standard) NotesPhysician referral 1Clinic referral 2HMO referral 3Transfer from a hospital (different facility)

4

Transfer from a skilled nursing facility

5

Transfer from another health care facility

6

Emergency room 7Court/law enforcement 8Information not available 9Transfer from one distinct unit of the hospital to another distinct unit of the hospital resulting in a separate claim to the payer

D

Transfer from ambulatory surgery center

E




(if different from Standard) NotesTransfer from a hospice facility

F

15)Race



(if different from Standard) NotesAmerican Indian or Alaska Native 1002-5

Asian 2028-9Black or African American 2054-5Native Hawaiian or Pacific Islander 2076-8

White 2106-3Other Race 2131-1

16)EthnicityStandard

DescriptionStandard


(if different from Standard) NotesHispanic or Latino HNot Hispanic or Latino NUnknown U

17)GenderStandard

DescriptionStandard


(if different from Standard) NotesAmbiguous AFemale FMale MOther OUnknown U


18)Plan Type Code



(if different from Standard) NotesMedicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan

12

Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan

13

Medicare Secondary, No-fault Insurance including Auto is Primary

14

Medicare Secondary Worker's Compensation

15

Medicare Secondary Public Health Service (PHS) or Other Federal Agency

16

Medicare Secondary Black Lung 41Medicare Secondary Veteran's Administration

42

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)

43

Medicare Secondary, Other Liability Insurance is Primary

47

Auto Insurance Policy APCommercial C1Consolidated Omnibus Budget Reconciliation Act (COBRA)

CO

Medicare Conditionally Primary CPDisability DDisability Benefits DBExclusive Provider Organization EPFamily or Friends FFGroup Policy GPHealth Maintenance Organization (HMO) HMHealth Maintenance Organization (HMO) - Medicare Risk

HN

Special Low Income Medicare Beneficiary HSIndemnity INIndividual Policy IPLong Term Care LCLong Term Policy LDLife Insurance LILitigation LTMedicare Part A MAMedicare Part B MBMedicaid MC




(if different from Standard) NotesMedigap Part A MHMedigap Part B MIMedicare Primary MPOther OTMedicare Other OTHMProperty Insurance - Personal PEPersonal PLPersonal Payment (Cash - No Insurance) PPPreferred Provider Organization (PPO) PRPoint of Service (POS) PSQualified Medicare Beneficiary QMProperty Insurance - Real RPSupplemental Policy SPTax Equity Fiscal Responsibility Act (TEFRA)

TF

Workers Compensation WCWrap Up Policy WU

19)Discharge Disposition Code



(if different from Standard) NotesUnknown/other 00Discharged to home or self-care (routine discharge)

01

Discharged/transferred to another short-term general hospital for inpatient care

02

Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care

03

Discharged/transferred to a facility that provides custodial or supportive care

04

Discharged/transferred to a designated cancer center or children's hospital

05

Discharged/transferred to home under care of organized home health service organization in anticipation of covered skilled care

06

Left against medical advice or discontinued care

07

Admitted as an inpatient to this hospital 09Expired 20Discharged/transferred to court/law enforcement

21

Still patient or expected to return for 30




(if different from Standard) Notesoutpatient servicesExpired at home 40Expired in a medical facility (e.g. hospital, SNF, ICF, or free standing hospice)

41

Expired - place unknown 42Discharged/transferred to a federal health care facility

43

Hospice - home 50Hospice - medical facility (certified) providing hospice level of care

51

Discharged/transferred to a hospital-based Medicare approved swing bed

61

Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital

62

Discharged/transferred to a Medicare certified long term care hospital (LTCH)

63

Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare

64

Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital

65

Discharged/transferred to a Critical Access Hospital (CAH)

66

Discharged/transferred to another type of health care institution not defined elsewhere in this code list

70


20)Marital Status CodeStandard

DescriptionStandard


(if different from Standard) NotesSeparated AUnmarried BCommon law CDivorced DLegally separated ELiving together GInterlocutory IMarried MAnnulled NOther ODomestic partner PRegistered domestic partner R

Single SUnreported TUnknown UWidowed W


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