1 Definition 2 Functional Requirements 3 Syntax 4 Semantics

1 Definition

A Clinical Record Qualifier specifies metadata describing a Clinical Record Data instance including:

  • the Type of clinical record (e.g. diagnosis, observation, procedure, medication, laboratory result),
  • the Representation and coding system used to encode the clinical record (e.g. ICD, SNOMED CT, LOINC),
  • the Clinical context and scope of the record (e.g. encounter‑based, longitudinal, problem‑oriented).

The Clinical Record Qualifier is used in conjunction with Clinical Record Data and is aggregated by a Clinical Record Object.

The combination of Clinical Record Data and Clinical Record Qualifier is called a Clinical Record Object, specified by AIH-HSP V1.0

The combination of EHR Data and EHR Qualifier is called EHR Object, specified by AIH-HSP V1.0.

2 Functional Requirements

ECG Qualifier must allow the expression of the following Elements:

  1. Sub-Type
  2. Format

Users needing support of other entries in MPAI-TFA should make a documented request to the MPAI Secretariat to consider addition of such entries.

3 Syntax

https://schemas.mpai.community/TFA/V1.5/data/ClinicalRecordQualifier.json

4 Semantics

Label Description
Header Clinical Record Qualifier Header – Standard “TFA‑CRQ‑Vx.y”.
ClinicalRecordType Type of clinical record described by the Clinical Record Data.
Examples include Diagnosis, Observation, Procedure, Medication, Laboratory Result, Vital Sign (symbolic), Allergy or Intolerance, Care Plan, Clinical Note (structured).
CodingSystem Coding or vocabulary system used to encode the clinical record.
Examples include ICD‑9, ICD‑10, ICD‑11, SNOMED CT, LOINC, ATC, RxNorm, or local EHR coding systems.
RecordRepresentation Representation form of the clinical record.
Examples include coded value, coded value with textual description, structured attribute‑value set.
ClinicalContext Clinical scope under which the record is valid.
Examples include encounter‑based, longitudinal patient record, problem‑oriented record, episode‑of‑care record.
EHRSource Indicator or identifier of the originating Electronic Health Record (EHR) system, if applicable.
DataXMData Information about this Clinical Record Qualifier Intsance.
DescrMetadata Descriptive Metadata.

5 References