Section I: Vocabulary/Code Set/Terminology Standards and Implementation Specifications

Printer Friendly, PDF & Email

Allergies and Intolerances

Representing Patient Allergic Reactions
Representing Patient Allergies and Intolerances; Medications
Representing Patient Allergies and Intolerances; Food Substances
Representing Patient Allergies and Intolerances; Environmental Substances

Encounter Diagnosis

Representing Patient Medical Encounter Diagnosis
Representing Patient Dental Encounter Diagnosis

Family Health History

Representing Patient Family Health History HITAC

Functional Status/Disability

Representing Patient Functional Status and/or Disability

Health Care Providers

Representing Health Care Providers
Representing Provider Role in Team Care Settings

Imaging (Diagnostics, Interventions and Procedures)

Representing Imaging Diagnostics, Interventions and Procedures

Immunizations

Representing Immunizations – Historical
Representing Immunizations – Administered

Industry and Occupation

Representing Patient Industry and Occupation

Lab Tests

Representing Laboratory Tests

Medications

Representing Patient Medications

Nursing

Representing Clinical/Nursing Assessments
Representing Nursing Interventions
Representing Outcomes for Nursing
Representing Patient Problems for Nursing

Patient Clinical “Problems” (i.e., conditions)

Representing Patient Clinical “Problems” (i.e., Conditions) HITAC

Preferred Language

Representing Patient Preferred Language (Presently)

Pregnancy Status

Representing Patient Pregnancy Status

Procedures

Representing Dental Procedures Performed
Representing Medical Procedures Performed

Race and Ethnicity

Representing Patient Race and Ethnicity

Research

Representing Analytic Data for Research Purposes

Sex at Birth, Sexual Orientation and Gender Identity

Representing Patient Gender Identity
Representing Patient-Identified Sexual Orientation
Representing Patient Sex (At Birth) HITAC

Social, Psychological, and Behavioral Data

Representing Financial Resource Strain
Representing Level of Education
Representing Stress
Representing Depression
Representing Physical Activity
Representing Alcohol Use
Representing Social Connection and Isolation
Representing Exposure to Violence (Intimate Partner Violence)

Tobacco Use (Smoking Status)

Representing Patient Tobacco Use (Smoking Status)

Unique Device Identification

Representing Unique Implantable Device Identifiers
Defining a Globally Unique Device Identifier
Transmitting a Unique Device Identifier

Units of Measure

Representing Units of Measure (For Use with Numerical References and Values)

Vital Signs

Representing Patient Vital Signs HITAC