On, ATCAllergia a farmaco: penicillinaPATIENT CLINICAL DATA
VARIABLE
(nesting level
1)
VARIABLES
(nesting level 2)
VARIABLES (nesting
level 3)
Allergy description
Alerts
Allergies and
intolerancess
Allergy description id code
Onset Date
Agent
Agent id code
Vaccinations
COMMENTS
Description of the clinical manifestation of
the allergy reaction. Example:
Anaphylactic shock, angioedema (the
clinical manifestation also gives
information about the the severity of the
observed reaction)
Normalized identifier
Date of the observation of the reaction
Describes the agent (drug, food, chemical
agent, etc) that is responsible for the
adverse reaction
Normalized identifier
Contains each disease against which
immunization was given
Brand name
Text and SCT code
MANDATORY
Yes/No
TEXT
Allergic rash
No
200769008
No
TEXT
1995
No
TEXT
Erythromycon
No
D10AF02
Pneumococcal
pneumonia
No
Prevnar (Wyeth)
No
TEXT
No
Vaccinations
History of past
illness
List of Resolved,
Closed or Inactive
problems
Vaccinations id code
Normalized identifier
333598008
No
Vaccination Date
The date the immunization was received
31/10/2013
No
Problem Description
Problems or diagnosis not included under
the definition of ‘Current problems or
diagnosis’. Example: hepatic cyst (the
patient has been treated with an hepatic
cystectomy that solved the problem and
therefore it´s a closed problem)
Fractured neck of
(left) femur
Problem Id (code)
On set time
End date
Resolution Circumstances
Normalized identifier
Date of problem onset
Problem resolution date
Describes the reason by which the
problem changed the status from current
to inactive (e.g. surgical procedure,
medical treatment, etc). This field includes
Lombardy
PS
S72
12/12/2007
No
No
No
No
No
TEXT
NOT FORESEEN
NOT FORESEEN
NOT FORESEEN
NOT FORESEEN
ICD9-CM.
FRATTURA DELLA
TESTA DEL
FEMORE,
CHIUSA:
821.23
Not mapped
12/07/2007
01/10/2007
On, ATCAllergia a farmaco: penicillinaPATIENT CLINICAL DATA
VARIABLE
(nesting level
1)
VARIABLES
(nesting level 2)
VARIABLES (nesting
level 3)
COMMENTS
Text and SCT code
MANDATORY
Yes/No
Lombardy
PS
‘free text’ if the resolution circumstances
are not already included in other fields.
Example: It can happen that this field is
already included in other like Surgical
Procedure, medical device etc, eg:
hepatic cystectomy (this wil be the
‘Resolution Circumstances’ for the
problem ‘hepatic cyst’ and will be included
in surgical procedures)
Problem Description
Problem Id (code)
On set time
End date
Resolution Circumstances
Surgical Procedures
prior to the past six
months
Medical
problems
List of Current
Problems/Diagnosis.
Procedure description
Procedure Id (code)
Procedure date
Problem/diagnosis
description
Describes the type of procedure
Normalized identifier
Date when procedure was performed
Problems/diagnosis that fit under these
conditions: conditions that may have a
chronic or relapsing course (eg:
exacerbations of asthma, irritable bowel
syndrome), conditions for which the
patient receives repeat medications (eg:
diabetes mellitus, hypertension) and
conditions that are persistent and serious
contraindications for classes of
medication (eg: dyspepsia, migraine and
asthma)
Migraine
headaches
ICD9-CM
EMICRANIA,
SENZA
MENZIONE
EMICRANIA NON
TRATTABILE
346.00
G43
1982
1998
“No longer getting
migraines”
Appendicectomy
80146002
1963
G43
31/12/1982
31/12/1998
“No longer getting
migraines”
TEXT
TEXT
TEXT
No
No
No
ICD9: 401.9
Hypertension
Hypertension
No
On, ATCAllergia a farmaco: penicillinaPATIENT CLINICAL DATA
VARIABLE
(nesting level
1)
VARIABLES
(nesting level 2)
VARIABLES (nesting
level 3)
Problem Id (code)
Onset time
Medical Devices and
implants
Major Surgical
Procedures in the
past 6 months1
Treatment
Recommendations
Device and implant
Description
Device Id code
Implant date
Procedure description
Procedure Id (code)
Procedure date
Recommendations
Description
Recommendation Id
(code)
Description
Autonomy/Invalidity
Invalidity Id code
List of current
medicines.
Medication
Summary
1
(All prescribed
medicine whose
period of time
indicated for the
Active ingredient
COMMENTS
Text and SCT code
MANDATORY
Yes/No
Normalized identifier
Date of problem onset
Describes the patient’s implanted and
external medical devices and equipment
that their health status depends on.
Includes devices as cardiac pacemakers,
implantable defibrillator, prothesis,
ferromagnetic bone implants etc that are
important to know by the HCP
Normalized identifier
I10
2008
No
No
Lombardy
PS
I10
01/07/2008
(none)
No
(none)
(none)
No
No
No
No
No
(none)
No
Describes the type of procedure
Normalized identifier
Date when procedure was performed
Therapeutic recommendations that do not
include drugs (diet, physical exercise
constraints, etc.)
Normalized identifier
Need of the patient to be continuously
assisted by third parties. Invalidity status
may influence decisions about how to
administer treatments
Normalized invalidity ID (if any, otherwise
free text)
Substance that alone or in combination
with one or more other ingredients
produces the intended activity of a
medicinal product. Example: Paracetamol
No
(nothing stated)
No
No
Metoprolol
No
Active ingredient id code
Code that identifies the Active ingredient
C07AB02
No
Strength
The content of the active ingredient
expressed quantitatively per dosage unit,
100mg
No
As there is subjectivity in the term ‘relevant’, the date will be used as the limit to include procedures.
Metoprololo
C07AB02
(100 mg)
On, ATCAllergia a farmaco: penicillinaPATIENT CLINICAL DATA
VARIABLE
(nesting level
1)
VARIABLES
(nesting level 2)
VARIABLES (nesting
level 3)
treatment has not yet
expired whether it
has been dispensed
or not.).
Pharmaceutical dose form
Number of units per
intake2
Frequency of intakes2
Social History
Pregnancy
History
Physical
findings
Social History
Observations
Expected date of
delivery
Vital Signs
Observations
Duration of treatment2
Date of onset of
treatment
Social History
Observations related to:
smoke, alcohol and diet.
Reference date range
Expected date of delivery
Blood pressure
Date when blood pressure
was measured
Result of blood group
Diagnostic
tests
Blood group
Date
2
COMMENTS
per unit of volume or per unit of weight,
according to the pharmaceutical dose
form. Example: 500 mg per tablet
It is the form in which a pharmaceutical
product is presented in the medicinal
product package (e.g. tablets, syrup)
The number of units per intake that the
patient is taking. Example: 1 tablet
Frequency of intakes (per
hours/day/month/ week..). Example: each
24 hours
Example: during 14 days
Date when patient needs to start taking
the medicine prescribed
Example: cigarette smoker, alcohol
consumption...
Example: from 1974 thru 2004
Date in which the woman is due to give
birth. Year, day and month are required.
Eg: 01/01/2010
One value of blood pressure which
includes: systolic Blood Pressure and
Diastolic Blood pressure
Date when blood pressure was measured
Result from the blood group test made to
the patient
Date in which the blood group test was
done. This field may contain only the year
if day and month are not available. Eg:
01/01/2009
Text and SCT code
MANDATORY
Yes/No
Tablets
No
One
No
Morning
No
Indefinite
No
7/2/2014
No
Non-smoker
No
Lombardy
PS
TEXT
TEXT
NO
0
No
(not applicable)
No
130/90
No
7/2/2014
No
(not recorded)
No
No
Posology has been defined from the functional point of view as containing these three components: number of units per intake, frequency of intakes and duration of treatment:(example: 1
unit/intake every 24 hours for a duration of 14 days
130/90
NO
NO
NO