HL7 v2 Data Requirements and Pre-work
Hospital/Provider Name, ST
Participant Pre-work
Audience:
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, ADTA34)?
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
HL7 v2 Data Requirements – WVHIN
HL7 v2 Data Requirements by Segment Specification ......................................................... 4
1)
MSH Segment Specification (Message Header) - Required .............................. 4
2)
PID Segment Specification (Patient Identification) - Required ........................... 4
3)
NK1 Segment Specification (Next of Kin) - Optional .......................................... 5
4)
PV1 Segment Specification (Patient Visit) - Required........................................ 5
5)
DG1 Segment Specification (Patient Diagnoses) - Required ............................. 7
6)
PR1 Segment Specification (Procedures Segment) - Desired ........................... 7
7)
IN1/IN2 Segment Specification (Insurance Segment) - Desired......................... 7
8)
Orders - Required.............................................................................................. 8
9)
Discrete Observations - Required...................................................................... 9
10) Observation Groups - Required ........................................................................10
11) Observation Results - Required........................................................................10
12) Medication Orders - Required ..........................................................................11
13) Medication Components - Required .................................................................12
14) Medications Administered - Desired .................................................................13
15) Report Text - Optional ......................................................................................14
16) Problems - Required ........................................................................................14
17) Allergies - Required ..........................................................................................15
18) Specimens - Optional .......................................................................................16
Coded Values ..................................................................................................................17
1)
Facility Codes ...................................................................................................17
2)
Allergen Type Code..........................................................................................17
3)
Allergen Severity Code .....................................................................................17
4)
Observations Result Status Code.....................................................................17
5)
Abnormal Flag Code ........................................................................................18
6)
Diagnosis Type Code .......................................................................................19
7)
Diagnosis Coding System Code .......................................................................19
8)
Diagnosis Priority .............................................................................................19
9)
Present on Admission Indicator Code...............................................................20
10) Procedure Coding System Type Code .............................................................20
11) Problem Action Code .......................................................................................20
12) Patient Class Code...........................................................................................21
13) Admission Type Code ......................................................................................21
14) Admission Source Code ...................................................................................21
15) Race.................................................................................................................22
December 2014 – v1
Page | 2
16) Ethnicity ...........................................................................................................22
17) Gender .............................................................................................................22
18) Plan Type Code ...............................................................................................24
19) Discharge Disposition Code .............................................................................25
20) Marital Status Code ..........................................................................................27
December 2014 – v1
Page | 3
HL7 v2 Data Requirements by Segment Specification
Please 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) - Required
Default
HL7
Location
Field Name
Standard Description
MSH.3
Sending Application
Name of application that sent HL7 message
MSH.4
Sending Facility
Name of healthcare facility that sent HL7 message
MSH.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) - Required
Default
HL7
Location
Field Name
Standard Description
PID.3.1
Local Patient Number
PID.4.1
Unique Patient Number
PID.5.1
Last Name
Identifier used by healthcare facility to uniquely identify a
patient. Also referred to as Medical Record Number.
Optional identifier used to uniquely identify a patient across
facilities within a hospital system. Also referred to as the
Unique Patient Identifier.
Last name of patient
PID.5.2
First Name
First name of patient
PID.5.3
Middle Name
Middle name (or initial) of patient
PID.7
Birth Date/Time
Patient's date of birth
PID.8
Gender Code
Patient's gender
PID.10
Race Code
Patient's race
PID.11.1
Street Address 1
First line of street address of patient's mailing address
PID.11.2
Street Address 2
Second line of street address of patient's mailing address
PID.11.3
Address City
City of patient's mailing address
PID.11.4
Address State
State of patient's mailing address
PID.11.5
Address Zip
Zip code
PID.11.6
Address Country
Country of patient's mailing address
PID.12
Address County
County of patient's mailing address
PID.13
Home Phone
Patient's home phone number
PID.14
Business Phone
Patient's business phone number
PID.15.2
Primary Language
Primary language spoken by patient
December 2014 – v1
Page | 4
Default
HL7
Location
Field Name
Standard Description
PID.16
Marital Status Code
Patient's marital status
PID.17
Religion Code
PID.18
Visit Number
PID.19
SSN
Patient's religion
Unique 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.
Patient’s Social Security Number
PID.22
Ethnic Group Code
Patient's ethnic group code
PID.30
Death Indicator Code
MRG.1.1
Prior Patient Number
Field indicates whether he patient is deceased. Valid values
are Y and N.
Used 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) - Optional
Default
HL7
Location
Field Name
Standard Description
NK1.2.1
Last Name
Last name of patient’s next of kin
NK1.2.2
First Name
First name of patient’s next of kin
NK1.2.3
Middle Name
Middle name (or initial) of patient’s next of kin
NK1.3
Relationship
Relationship of next of kin to patient
NK1.4.1
Street Address 1
First line of street address of next of kin's mailing address
NK1.4.2
Street Address 2
Second line of street address of next of kin's mailing address
NK1.4.3
Address City
City of next of kin's mailing address
NK1.4.4
Address State
State of next of kin's mailing address
NK1.4.5
Address Zip
Zip code of next of kin's mailing address
NK1.4.6
Address Country
Country of next of kin's mailing address
NK1.4.9
Address County Code
County of next of kin's mailing address
NK1.5
Home Phone
Next of kin's home phone number
NK1.6
Business Phone
Next of kin's business phone number
4) PV1 Segment Specification (Patient Visit) - Required
Default
HL7
Location
Field Name
PV1.2
Patient Class Code
PV1.3.1
Point of Care
December 2014 – v1
Standard Description
Used to categorize patients (inpatient, outpatient,
emergency, obstetrics, etc)
Description of patient's assigned location, or location to which
patient is being moved. Also known as ward or unit.
Page | 5
Default
HL7
Location
Field Name
Standard Description
Patient's assigned room, or the room to which patient is being
moved
Patient's assigned bed, or the bed to which patient is being
moved
Circumstances under which patient was or will be
admitted
PV1.3.2
Room
PV1.3.3
Bed
PV1.4
Admission Type Code
PV1.7.1
Attending Doctor
PV1.8.1
Referring Doctor
PV1.9.1
Consulting Doctor
PV1.10
Hospital Service
PV1.14
Admission Source Code
Treatment or type of surgery that patient is scheduled to
receive (e.g., cardiac, medical, pulmonary, etc)
Indicates where patient was admitted
PV1.16
VIP Indicator
Site-specific value indicating if the patient is a VIP
PV1.17.1
Admitting Doctor
PV1.18
Patient Type
PV1.19
Visit Number
PV1.20.1
Financial Class
PV1.20.2
PV1.36
PV1.37.1
Financial Class Effective
Date/Time
Discharge Disposition
Code
Site-specific values that identify patient type
Unique 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.
Site-specific values that identify financial class(es) assigned to
patient for purpose of identifying sources of reimbursement
Effective date of Financial Class
Contains disposition of patient at time of discharge
Healthcare facility to which patient was discharged
PV1.44
Discharge To Location
Discharge To Location
Date/Time
Admit Date/Time
PV1.45
Discharge Date/Time
Discharge date/time
PV1.52.1
Other Healthcare Provider
PV2.3
Reason for Visit
PV2.38
Mode of Arrival
PV2.40
Admission Level of Care
PD1.4.1
Patient Primary Care
Provider
MRG.3
Prior Visit Number
PV1.37.2
December 2014 – v1
Discharge date associated with Discharged To Location Code
Admit date/time
Short description of the reason for patient visit
Site-specific code indicating how patient was brought to
healthcare facility (i.e. ambulance, car, etc)
Indicates acuity level assigned to patient at time of admission
(e.g., acute, chronic, critical)
Used only in visit merge messages, this field contains prior
visit identifier
Page | 6
5) DG1 Segment Specification (Patient Diagnoses) - Required
Default
HL7
Location
Field Name
DG1.3.1
Diagnosis Code
DG1.3.2
Diagnosis Description
Diagnosis Coding
System Code
DG1.3.3
DG1.5
Diagnosis Date/Time
DG1.6
Diagnosis Type Code
DG1.15
Diagnosis Priority
DG1.26
Present on Admission
Indicator Code
Standard Description
Uniquely identifies a particular diagnosis. This element may
conform to some external, standard coding system or it may
be local code or free text
Description supplied by hospital for Diagnosis Code
Coding system used in Diagnosis Code field (e.g., ICD9,
ICD10 or Snomed CT)
Date/time that diagnosis was determined
Identifies type of diagnosis being sent (i.e., admitting,
working or final)
Identifies significance or priority of diagnosis 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) - Desired
Default
HL7
Location
Field Name
PR1.3.1
Procedure Code
PR1.3.2
Procedure Description
Procedure Coding
System Type Code
PR1.3.3
PR1.14
Procedure Priority
PR1.16
Procedure Code Modifier
Standard Description
Uniquely identifies a particular procedure. This element may
conform to some external, standard coding system or it may
be local code or free text.
Description supplied by hospital for Procedure Code
Coding system used in Procedure Code field (e.g., ICD9
or CPT)
Number that identifies significance or priority of procedure
code
Procedure code modifier to Procedure Code, when applicable
7) IN1/IN2 Segment Specification (Insurance Segment) - Desired
Default
HL7
Location
Field Name
Standard Description
IN1.2.1
Plan Number
Site-specific identifier for insurance plan
IN1.2.2
Plan Name
Name of insurance plan
IN1.3
Company Number
Site-specific identifier for insurance company
IN1.36
Insured's Policy Number
Individual policy number of insured to identify patient's plan
IN1.4
Company Name
Name of insurance company
IN1.45
Verification Status
Status of patient's relationship with insurance carrier
IN1.5.1
Company Street
Street of insurance company's mailing address
December 2014 – v1
Page | 7
Default
HL7
Location
Field Name
Standard Description
IN1.5.3
Company City
City of insurance company's mailing address
IN1.5.4
Company State
State of insurance company's mailing address
IN1.5.5
Company Zip
Zip code of insurance company's mailing address
IN1.5.6
Company Country
Country of insurance company's mailing address
IN1.7
Company Phone
Phone number of insurance company
IN1.8
Group Number
Group number of insured's insurance
IN1.9
Group Name
Group name of insured's insurance
IN1.11
Employer Name
Name of employer that provides employee's insurance
IN1.15
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 - Required
The 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
ORC.3.1
Filler Order Number
ORC.2.1
Placer Order Number
ORC.3.1
Unique Order Number
OBR.4.1
Service Code
OBR.4.3
Service Coding System
OBR.4.2
Service Name
ORC.7.1
Quantity
ORC.7.2
Interval
Description supplied by hospital for Service Code
Numeric 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".
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 order
OBR.7.5
End Date/Time
Explicit end date and time for medication order
ORC.7.6
Priority
Priority of request (e.g., stat or routine)
December 2014 – v1
Describes function of order segment within message
Identification number that is assigned by application that filled
order
Identification number that is assigned by application that
placed order
Unique identification number for medication order. This may
be Filler Order Number, Placer Order Number, or
concatenation of the two
Uniquely 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.
Coding system used in Service Code
Page | 8
Default
HL7
Location
Field Name
ORC.7.7
Condition
ORC.9
Transaction Date/Time
Standard Description
Free text field that describes condition under which service
should be performed. Also known as PRN.
Date and time of event that initiated current transaction, as
defined in Order Control Code
Explanation of reason for order event described by Order
Control Code. This field may be either coded or free text form.
Type of order (e.g., lab order or microbiology order)
MSH.3
Order Control Code
Reason
Category
NTE.3
Note
OBR.16.1
Caregiver Number
OBR.16.2
Last Name
Any free text notes associated with lab order
Healthcare facility's identification code for provider who
ordered material or service
Ordering provider's last name
OBR.16.3
First Name
Ordering provider's first name
ORC.16
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
OBX.1
ORC.3.1
Field Name
Sequence Number
Order Unique Order
Number
OBX.3.1
Observation Type Code
OBX.3.2
Observation Type Name
Observation Type Coding
System
OBX.3.3
OBX.5
Observation Value
NTE.3
Note
December 2014 – v1
Standard Description
Sequence number of this observation within order message
Unique identification number for order, repeated from Orders
Unique Order Number field.
Uniquely 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.
Description supplied by hospital for Observation Type Code
Coding system used in Observation Type Code
Value provided in this observation (e.g., textual description of
reason for a radiology exam)
Any free text notes associated with order observation
Page | 9
10) Observation Groups - Required
The 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
OBR.1
Sequence Number
OBR.2.1
Placer Order Number
OBR.3.1
Filler Order Number
OBR.3.1
Unique Order Number
OBR.4.1
Service Code
OBR.4.2
Service Name
OBR.4.3
Service Coding System
OBR.7.1
Observation Date/Time
OBR.16.1
Caregiver Number
OBR.16.2
Last Name
OBR.16.3
First Name
OBR.22
Observation Report Status
Date/Time
OBR.25
Result Status Code
NTE.3
Note
Standard Description
Sequence number of this observation within message
Identification number assigned by application that placed
medication order
Identification number assigned by application that filled lab
order
Unique identification number for order. May be Filler Order
Number, Placer Order Number, or concatenation of the two
Uniquely identifies particular type of observation. This element
may conform to some external, standard coding system or
may be a local code
Description supplied by hospital for Observation Type Code
Coding system used in Service Code
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
Healthcare facility's identification number for provider who
ordered observation
Ordering provider's last name
Ordering provider's first name
Date and time results are composed into report and
released, or that a status, or defined in Order Status, is
entered or changed
Status of results for this order
Any free text notes associated with the vital signs observation
results
11) Observation Results - Required
The 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
OBX.1
OBR.3.1
OBX.3.1
Field Name
Sequence Number
Observation Group
Unique Order Number
Observation Type Code
December 2014 – v1
Standard Description
Sequence number of lab result (within message)
Unique identification number for order, repeated from
Observation Group Unique Order Number
Uniquely identifies particular type of observation.
Page | 10
Default
HL7
Location
OBX.3.2
Field Name
Standard Description
This element may confirm to some external, standard coding
system or may be local code or free text
Description supplied by hospital for Observation Type Code
OBX.5
Observation Type Name
Observation Type Coding
System Code
Observation Value
OBX.6
Observation Units
Hospital-supplied unit of measure for Observation Value
OBX.7
Reference Range
Normal range for specific numeric laboratory result value
OBX.8
Abnormal Flag Code
Code indicating normalcy status of result
OBX.11
Result Status Code
Status of results for this order
OBX.3.3
OBX.14
Observation Date/Time
NTE.3
Note
Coding system used in Observation Type Code
Hospital-supplied value for observation
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
Any free text notes associated with lab or vitals observation
result
12) Medication Orders - Required
The 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
Location
Field Name
Standard Description
ORC.1
Order Control Code
ORC.2
Placer Order Number
ORC.3
Filler Order Number
ORC.3
Unique Order Number
ORC.5
Order Status Code
ORC.9
Transaction Date/Time
ORC.12.1
Caregiver Number
ORC.12.2
Last Name
Describes function of order segment within message (e.g.
"NW" (new) or "CA" (cancel order)
Identification number assigned by application that placed
medication order
Identification number assigned by application that filled
medication order
Unique identification number for medication order. This may
be Filler Order Number, Placer Order Number, or a
concatenation of the two.
Describes status of order (e.g., completed, discontinued, etc.)
Date and time of event that initiated current transaction, as
defined in Order Control Code
Healthcare facility's identification number for provider who
ordered medication
Ordering provider's last name
ORC.12.3
First Name
Ordering provider's first name
December 2014 – v1
Page | 11
Default
HL7
Location
Field Name
Standard Description
RXE.1.1
Quantity
RXE.1.2
Interval
RXE.1.3
Duration
Numeric quantity of medication that should be provided at
each service interval
Interval at which medication should be provided (e.g., “every 4
hours”)
Duration of medication order (e.g., "for 3 days")
RXE.1.4
Start Date/Time
Explicit start date and time for medication order
RXE.1.5
End Date/Time
Explicit end date and time for medication order
RXE.1.6
Priority
RXE.1.7
Condition
RXE.3
Minimum Dose
RXE.4
Maximum Dose
RXE.5.1
RXE.23
Dose Units
Provider Administration
Instructions
Supplier Administration
Instructions
Dose Rate Amount
Priority of request (e.g., stat or routine)
Condition on which medication should be given (e.g., "as
needed for pain". Also known as PRN)
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
In variable dose order, this is maximum ordered amount. In
non-varying dose, field not used
Units for Minimum Dose and Maximum Dose fields
Ordering provider's instructions to patient or provider
administering drug
Pharmacy or treatment supplier's provider-generated special
instructions to provider dispensing/administering order
Rate at which substance should be administered
RXE.24
Dose Rate Units
Units for Dose Rate Amount
RXR.1.1
Route
NTE.3
Note
Site-specific route of administration from medication order
Any additional free text notes associated with medication
ordered
RXE.7.2
RXE.21
13) Medication Components - Required
The 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
RXE.2.1
or
RXC.2.1
RXE.2.2
or
Field Name
Standard Description
Component Code
Uniquely 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
Component Name
Description supplied by hospital for Component Code
December 2014 – v1
Page | 12
Default
HL7
Location
Field Name
Standard Description
RXC.2.2
RXE.2.3
or
RXC.2.3
RXE.10
or
RXC.3
RXE.11
or
RXC.4
RXE.31.1
or
RXC.7.1
RXE.31.2
or
RXC.7.2
RXE.31.3
or
RXC.7.3
Component Coding
System
Coding system used in Component Code
Component Amount
Amount to be dispensed, as encoded by pharmacy or
treatment supplier
Component Units
Contains units for Component Amount as encoded by
pharmacy or treatment supplier
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).
Supplementary Name
Description supplied by hospital for Supplementary Code
Supplementary Coding
System
Coding system used in Supplementary Code
14) Medications Administered - Desired
The 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
Location
RXA.2
RXA.3
RXA.4
Field Name
Administration Counter
Administration Start
Date/Time
Administration End
Date/Time
RXA.5.1
Medication Code
RXA.5.2
RXA.6
Medication Name
Medication Coding
System
Administered Amount
RXA.7
Administered Units
RXA.9.2
Administration Notes
RXA.5.3
December 2014 – v1
Standard Description
Starts with ‘1’ first time that medication/treatment is
administered for this order, and increments by one with each
additional administration of medication/treatment
Date and time administration of medication was started
Date and time administration of medication was ended
Site-specific identifier of medical substance/treatment
administered
Description supplied by hospital for Medication Code
Coding system used in Medication Code
Contains amount administered
Must be in simple units that reflect actual quantity of
substance administered. Does not include compound units
Notes from provider administering medication/treatment
Page | 13
Default
HL7
Location
Field Name
RXA.18
Refusal Reason
RXA.20
Completion Status
RXR.1.1
Route
NTE.3
Note
Standard Description
Reason patient refused medical substance/
treatment. Any entry in field indicates patient did not take
substance
Site-specific status of treatment administration event (i.e.,
completed, refused, not administered)
Site-specific code for route by which medication was
administered
Any free text notes associated with medication administered
15) Report Text - Optional
The 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
Location
Field Name
OBR.4.2
Observation Group
Unique Order Number
Report Text Header
OBX.5
Report Text Body
NTE.3
Note
OBR.3.1
Standard Description
Unique identification number for report, repeated from
Observation Group Unique Order Number
Brief text that describes report (e.g., "CHEST PA LAT")
Body 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
Any free text notes associated with report text component
16) Problems - Required
The 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
PRB.1
Action Code
PRB.2
Action Date/Time
PRB.3.1
Problem Code
PRB.3.2
Problem Description
Problem Coding System
Code
Problem Number
PRB.3.3
PRB.4.1
December 2014 – v1
Standard Description
Code that describes intent of message
Date/time that operation represented by action code was
performed
Identifies 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
Description supplied by hospital for Problem Code
Coding system used in Problem Code field
Identifier assigned by initiating system to instance of problem
Page | 14
Default
HL7
Location
Field Name
Standard Description
PRB.12
Problem Established
Date/Time
Actual Problem Resolution
Date/Time
Problem Persistence
PRB.14.1
Problem Life Cycle Status
PRB.16
Problem Onset Date/Time
Perseverance of problem (e.g., acute, chronic, etc.)
Current status of problem (e.g., active, active-improving,
active-stable, active worsening, inactive, resolved, etc.)
Date/time when problem began
NTE.3
Note
Any free text notes associated with problem
PRB.7
PRB.9
Date/time when corresponding problem initially identified by
caregiver
Date/time that problem actually resolved
17) Allergies - Required
The 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
AL1.2 or
IAM.2
AL1.3.1
or
IAM.3.1
AL1.3.2
or
IAM.3.2
AL1.3.3
or
IAM.3.3
AL1.4 or
IAM.4
AL1.5 or
IAM.5
AL1.6 or
IAM.11
IAM.6.1
Field Name
Standard Description
Allergen Type Code
General allergy category (drug, food, pollen, etc.)
Allergen Code
Uniquely identifies particular allergen. Element may conform
to some external, standard coding system or it may be local
code or free text
Allergen Description
Description supplied by hospital for Allergen Code
Allergen Coding System
Code
Coding system used in Allergen Code field
Allergy Severity
Allergy Reaction
Site-specific value that indicates general severity of
allergy (e.g. mild, moderate, severe, etc.)
Site-specific value that indicates specific allergic reaction
documented (i.e., itching, nausea, etc.)
Onset Date/Time
Date and time allergy was identified
Allergy Action Code
Defines status of record, (e.g., add/insert, update, delete).
Allows hospitals to send allergy messages that delete or
update previously sent allergy messages.
December 2014 – v1
Page | 15
18) Specimens - Optional
The 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
Location
Field Name
SPM.2
Specimen Number
SPM.4.1
Specimen Type Code
SPM.4.2
Specimen Type
Specimen Type Coding
System
Specimen Source Site
Code
Specimen Source Site
Specimen Source Site
Coding System
SPM.4.3
SPM.8.1
SPM.8.2
SPM.8.3
December 2014 – v1
Standard Description
Unique identifier for specimen, as referenced by placer
application, filler application, or both
Site-specific code for specimen type
Name of specimen type
Coding system used in Specimen Type Code field
Code describing body site for specimen collection
Name of body site for specimen collection
Coding system used in Specimen Source Site Code field
Page | 16
Coded Values
Please provide your Hospital/Clinic Codes in each of the tables below if different from the
Standard Code listed for each description.
1) Facility Codes
Please 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 Description
Standard
Code
Animal allergy
AA
Drug allergy
DA
Environmental allergy
EA
Food allergy
FA
Pollen allergy
LA
Miscellaneous allergy
MA
Miscellaneous contraindication
MC
Plant allergy
PA
Hospital/Clinic Code
(if different from Standard)
Notes
3) Allergen Severity Code
Standard Description
Standard
Code
Mild
MI
Moderate
MO
Severe
SV
Unknown
Hospital/Clinic Code
(if different from Standard)
Notes
U
4) Observations Result Status Code
Standard Description
Standard
Code
Record coming over is a
correction and thus replaces a
final result
Deletes the OBX record
C
Final results; Can only be
changed with a corrected result.
Specimen in lab; results pending
F
December 2014 – v1
Hospital/Clinic Code
(if different from Standard)
D
I
Page | 17
Notes
Standard Description
Standard
Code
Not asked; used to affirmatively
document that the observation
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)
Preliminary results
Hospital/Clinic Code
(if different from Standard)
Notes
N
O
P
Results entered -- not verified
R
Partial results. Deprecated.
Retained only for backward
compatibility as of V2.6.
Results status change to final
without retransmitting results
already sent as 'preliminary.'
E.g., radiology changes status
from preliminary to final
Post original as wrong, e.g.,
transmitted for wrong patient
Results cannot be obtained for
this observation
S
U
W
X
5) Abnormal Flag Code
Standard Description
Standard
Code
Below absolute low-off instrument scale
<
Above absolute high-off instrument scale
>
Abnormal (applies to non-numeric results)
A
Very abnormal (applies to non-numeric
units, analogous to panic limits for numeric
units)
Anti-complementary substances present
AA
AC
Better-use when direction not relevant
B
Significant change down
D
Detected
Above high normal
Above upper panic limits
Intermediate. Indicates for microbiology
susceptibilities only.
Indeterminate
December 2014 – v1
DET
H
HH
I
IND
Page | 18
Hospital/Clinic Code
(if different from Standard)
Notes
Standard
Code
Standard Description
Below low normal
L
Below lower panic limits
LL
Moderately susceptible. Indicates for
microbiology susceptibilities only.
Normal (applies to non-numeric results)
MS
Not Detected
ND
Negative
Hospital/Clinic Code
(if different from Standard)
N
NEG
Non-reactive
NR
Positive
POS
Quality Control Failure
QCF
Resistant. Indicates for microbiology
susceptibilities only.
Reactive
R
RR
Susceptible. Indicates for microbiology
susceptibilities only.
Cytotoxic substance present
Significant change up
S
TOX
U
Very susceptible. Indicates for microbiology
susceptibilities only.
Worse-use when direction not relevant
VS
Weakly reactive
WR
W
6) Diagnosis Type Code
Standard
Description
Standard
Code
Admitting
A
Final
F
Working
W
Hospital/Clinic Code
(if different from Standard)
Notes
7) Diagnosis Coding System Code
Standard Description
Standard
Code
ICD-9
I9
ICD-10
I10
Snomed Clinical Terms
Hospital/Clinic Code
(if different from Standard)
SCT
8) Diagnosis Priority
December 2014 – v1
Page | 19
Notes
Notes
Standard Description
Not included in diagnosis
ranking
The primary diagnosis
Standard
Code
Hospital/Clinic Code
(if different from Standard)
Notes
0
1
First other diagnosis
2
Second other diagnosis
3
9) Present on Admission Indicator Code
Standard Description
Standard
Code
Yes
Y
No
N
Exempt
E
Unknown
U
Not Applicable
W
Hospital/Clinic Code
(if different from Standard)
Notes
10) Procedure Coding System Type Code
Standard Description
CPT
Standard
Code
Notes
CPT
ICD-9
I9
ICD-10
I10
HCPCS
HCPCS
Snomed Clinical Terms
Hospital/Clinic Code
(if different from Standard)
SCT
11) Problem Action Code
Standard Description
Standard
Code
Add
AD
Correct
CO
Delete
DE
Link
LI
Unchange
UC
Unlink
UN
Update
UP
December 2014 – v1
Hospital/Clinic Code
(if different from Standard)
Page | 20
Notes
12) Patient Class Code
Standard Description
Standard
Code
Inpatient
I
Outpatient
O
Emergency
E
Obstetrics
B
Pre-admit
P
Recurring
R
Unknown
U
Not Applicable
N
Hospital/Clinic Code
(if different from Standard)
Notes
13) Admission Type Code
Standard Description
Standard
Code
Elective
C
Emergency
E
Urgent
U
Accident
A
Labor and Delivery
L
Newborn
N
Routine
R
Hospital/Clinic Code
(if different from Standard)
Notes
14) Admission Source Code
Standard Description
Standard
Code
Physician referral
1
Clinic referral
2
HMO referral
3
Transfer from a hospital
(different facility)
Transfer from a skilled nursing
facility
Transfer from another health
care facility
Emergency room
4
Court/law enforcement
8
Information not available
9
Transfer from one distinct unit
of the hospital to another
distinct unit of the hospital
D
December 2014 – v1
Hospital/Clinic Code
(if different from Standard)
5
6
7
Page | 21
Notes
Standard
Code
Standard Description
resulting in a separate claim
to the payer
Transfer from ambulatory
surgery center
Transfer from a hospice
facility
Hospital/Clinic Code
(if different from Standard)
Notes
E
F
15) Race
Standard
Code
Standard Description
American Indian or Alaska
Native
Asian
Hospital/Clinic Code
(if different from Standard)
Notes
1002-5
2028-9
Black or African American
Native Hawaiian or Pacific
Islander
White
2054-5
Other Race
2131-1
2076-8
2106-3
16) Ethnicity
Standard
Description
Standard
Code
Hispanic or Latino
H
Not Hispanic or Latino
N
Unknown
U
Hospital/Clinic Code
(if different from Standard)
Notes
17) Gender
Standard
Description
Standard
Code
Ambiguous
A
Female
F
Male
M
Other
O
Unknown
U
December 2014 – v1
Hospital/Clinic Code
(if different from Standard)
Page | 22
Notes
December 2014 – v1
Page | 23
18) Plan Type Code
Standard Description
Standard
Code
Medicare Secondary Working Aged
Beneficiary or Spouse with Employer Group
Health Plan
Medicare Secondary End-Stage Renal
Disease Beneficiary in the 12 month
coordination period with an employer's
group health plan
Medicare Secondary, No-fault Insurance
including Auto is Primary
Medicare Secondary Worker's
Compensation
Medicare Secondary Public Health Service
(PHS) or Other Federal Agency
Medicare Secondary Black Lung
12
Medicare Secondary Veteran's
Administration
Medicare Secondary Disabled Beneficiary
Under Age 65 with Large Group Health Plan
(LGHP)
Medicare Secondary, Other Liability
Insurance is Primary
Auto Insurance Policy
42
AP
Commercial
C1
Consolidated Omnibus Budget
Reconciliation Act (COBRA)
Medicare Conditionally Primary
CO
Disability
13
14
15
16
41
43
47
CP
D
Disability Benefits
DB
Exclusive Provider Organization
EP
Family or Friends
FF
Group Policy
GP
Health Maintenance Organization (HMO)
HM
Health Maintenance Organization (HMO) Medicare Risk
Special Low Income Medicare Beneficiary
HN
Indemnity
IN
Individual Policy
IP
Long Term Care
LC
Long Term Policy
LD
Life Insurance
LI
Litigation
LT
Medicare Part A
MA
December 2014 – v1
HS
Page | 24
Hospital/Clinic Code
(if different from Standard)
Notes
Standard Description
Standard
Code
Medicare Part B
MB
Medicaid
MC
Medigap Part A
MH
Medigap Part B
MI
Medicare Primary
MP
Other
OT
Medicare Other
Hospital/Clinic Code
(if different from Standard)
Notes
OTHM
Property Insurance - Personal
PE
Personal
PL
Personal Payment (Cash - No Insurance)
PP
Preferred Provider Organization (PPO)
PR
Point of Service (POS)
PS
Qualified Medicare Beneficiary
QM
Property Insurance - Real
RP
Supplemental Policy
SP
Tax Equity Fiscal Responsibility Act
(TEFRA)
Workers Compensation
TF
WC
Wrap Up Policy
WU
19) Discharge Disposition Code
Standard Description
Standard
Code
Unknown/other
00
Discharged to home or self-care (routine
discharge)
Discharged/transferred to another shortterm general hospital for inpatient care
Discharged/transferred to skilled nursing
facility (SNF) with Medicare certification in
anticipation of skilled care
Discharged/transferred to a facility that
provides custodial or supportive care
Discharged/transferred to a designated
cancer center or children's hospital
Discharged/transferred to home under care
of organized home health service
organization in anticipation of covered
skilled care
Left against medical advice or discontinued
care
01
December 2014 – v1
02
03
04
05
06
07
Page | 25
Hospital/Clinic Code
(if different from Standard)
Notes
Standard Description
Standard
Code
Admitted as an inpatient to this hospital
09
Expired
20
Discharged/transferred to court/law
enforcement
Still patient or expected to return for
outpatient services
Expired at home
21
Expired in a medical facility (e.g. hospital,
SNF, ICF, or free standing hospice)
Expired - place unknown
41
Discharged/transferred to a federal health
care facility
Hospice - home
43
Hospice - medical facility (certified)
providing hospice level of care
Discharged/transferred to a hospital-based
Medicare approved swing bed
Discharged/transferred to an inpatient
rehabilitation facility (IRF) including
rehabilitation distinct part units of a hospital
Discharged/transferred to a Medicare
certified long term care hospital (LTCH)
Discharged/transferred to a nursing facility
certified under Medicaid but not certified
under Medicare
Discharged/transferred to a psychiatric
hospital or psychiatric distinct part unit of a
hospital
Discharged/transferred to a Critical Access
Hospital (CAH)
Discharged/transferred to another type of
health care institution not defined elsewhere
in this code list
51
December 2014 – v1
30
40
42
50
61
62
63
64
65
66
70
Page | 26
Hospital/Clinic Code
(if different from Standard)
Notes
20) Marital Status Code
Standard
Description
Standard
Code
Separated
A
Unmarried
B
Common law
C
Divorced
D
Legally separated
E
Living together
G
Interlocutory
I
Married
M
Annulled
N
Other
O
Domestic partner
Registered domestic
partner
Single
P
R
Unreported
T
Unknown
U
Widowed
W
December 2014 – v1
Hospital/Clinic Code
(if different from Standard)
S
Page | 27
Notes