HL7 Version 3 Diet Orders
Domain Analysis Model Use Cases and Storyboards
Draft v 1.1
05/14/2011
Authors:
Members of American Dietetic Association Nutrition Informatics Committee:
Elaine Ayres
Joan Hoppe
Bill Swan
Curt Calder
Amy Miller
Anne Lougher
Margaret Dittloff
Marty Yadrick
Mary Jane Rogalski
Lindsey Hoggle
Jessie Pavlinac
Nisha Jain
Trudy Euler
1
Table of Contents
Introduction ................................................................................................................................................ 4
Storyboard Sample Format ......................................................................................................................... 7
Storyboard Topic ..................................................................................................................................... 7
Storyboard Actors and Roles .................................................................................................................. 7
Pre-Condition .......................................................................................................................................... 7
Sequence of Events, Storyboard, Activities ............................................................................................ 7
Post Condition ......................................................................................................................................... 7
Diet Order Storyboards and Use Cases ....................................................................................................... 8
Use Case 1: Order New Diet—General/Healthful (unrestricted) Diet .................................................... 8
Use Case 2: Order New Diet with Quantitative, Nutrient-based Modifications .................................. 11
Use Case 3: Texture/Consistency Modifications ................................................................................. 13
Use Case 4: Diet Order change to ‘NPO for Tests’ ................................................................................ 15
Use Case 5: Pediatric Specialty Orders – NEED TO DOCUMENT .......................................................... 17
Use Case 6: Order Oral Nutritional Supplement .................................................................................. 19
Use Case 7: Order Enteral Nutrition (Tube Feeding) ........................................................................... 22
Use Case 8: Meal/Special Service Designation Order .......................................................................... 26
Use Case 9: Request RD/Nutrition Consult .......................................................................................... 28
Glossary ..................................................................................................................................................... 37
References and Acronyms ........................................................................................................................ 39
Appendix: Storyboard naming standards ................................................................................................ 40
2
3
Introduction
Computerized Food and Nutrition Service Management Systems (FNMS) used by dietetics and
foodservice departments in hospitals and long-term care facilities depend on HL7 interfaces to
exchange data with hospital information systems (HIS), electronic health records (EHR) and
computerized physician order entry (CPOE) systems. The core function of these interfaces is the
electronic transmission and exchange of medically-based diet orders, tube feeding and nutritional
supplement orders, dietary intolerances and food allergies along with patient/resident food preference
information required to provide inpatients with nutritionally/culturally appropriate meals. The orders
interface capabilities of different FNMS varies by vendor; the majority support one-way, inbound
messages while some may support bi-directional interfaces. The procedure for acknowledging
nutrition orders also varies among institutions; for instance, in many institutions the order is verified by
nursing prior to transmission to the FNMS.
Diet and nutritional supplement orders are an important part of the medical nutrition therapy. This
coded information is used by nutrition software systems to control and customize the foods that get
offered and served to patients/residents as part of their plan of care.
A hospital or long-term care
facility Food & Nutrition Services department needs a diet order to notify them that a patient is able
and allowed to eat. A diet order is comprised of one or more diet specifications (often called diet
codes, modifications or restrictions). A patient can have only one effective diet order at a time. The
composite list of diet specifications in a diet order indicate what foods a patient should or should not
receive. This may involve controlling the type, texture and/or quantity of foods and nutrients that the
patient should receive. Often a complete diet order consists of a single diet code, such as ‘General
Healthy/Standard’ which is unrestricted in the amount or type of foods offered.
Diet codes can govern foods in a number of ways. In some cases, such as a gluten-free diet or a diet
code representing a food allergy, certain foods are contraindicated. In other cases, the diet implies a
recommended amount of one or more nutrients. “Some diet codes can combine to make a single diet
order. A 1500-Calorie restriction and a 2-gram sodium (NA2GM) restriction can coexist since they do
not address the same nutrient.” Certain kinds of diet codes cannot be combined with other codes, such
4
as NPO (Nothing by mouth) or use of more than one code for a given quantity of a nutrient, e.g., 1500Calorie and 2000-Calorie. It is impossible to feed a patient at two different calorie levels at the same
time. “These constraints are not defined in the table, but rather are implied by the semantics of the
codes.”(Chapter 4: Order Entry Page 4-98 Health Level Seven, Version v2.5.1 © 2007.)
A recognized standard or controlled vocabulary of diets or diet codes does not currently exist. Each
hospital institution or group will define a list of diet codes for use at their facility. However, most
localized diet descriptions or codes can be categorized as requiring either qualitative adjustments such
as texture modifications to assist a patient with chewing or swallowing disorders; or quantitative
modifications to control the amount of certain nutrients per day. Nutrient-based diets are ordered in
amounts per 24 hours and may then be arbitrarily divided up among multiple meals and/or between
meal snacks according to the patient’s typical eating behavior or the operational processes of each
medical facility. A dietitian may recommend that a patient receive a nutritional supplement or protein
sandwich between main meals to help the patient meet the daily nutrient totals for a diet. Suggested
diet taxonomy (see appendix #) compiled by the Nutrition Care Process/Standardized Language
Committee of the American Dietetic Association includes the following basic categories of diets:




Oral Diets
o General/Healthful (to include age-appropriate modifications, e.g., toddler)
o Texture/Consistency Modified
o Allergy/Intolerance – to eliminate or limit foods with specific ingredients i.e. gluten-free
o Quantitative Nutrient-based Modifications
 Energy Modified
 Carbohydrate Modified
 Protein & Amino Acid Modified
 Fluid Modified (Restricting or limiting consumption of total fluids)
 Mineral Modified (sodium, potassium, phosphorus, etc.)
Medical Nutritional Supplements
o Ordered b y Generic Description of Product Formulation, e.g., High Protein/2.0 Kcal formula
o Ordered by Specific Product/Manufacturer ID
Enteral Nutrition (for tube feedings)
Parenteral Nutrition (as these are generally pharmacy orders, they will not be addressed here)
5
Diets are typically ordered by a physician (or other licensed independent practitioner – LIP) or in some
cases by a licensed dietitian/nutritionist with clinical privileges, delegated authority or per established
protocols. Diet orders should designate a start time or meal for which the new diet order is to take
effect. This start time may be a specific time (either now or in the future) or for a designated meal or
snack period. Under certain circumstances, a diet order will have a specified end date/time or
expiration time if it is part of transitional orders for diet progressions or required for certain medical
procedures or tests. More often a diet order will have no end or stop date/time and will continue so
the patient is fed until the order is cancelled, revised or a replaced by a new order.
The intent of this document is to describe the diet and nutrition order storyboards, use cases and flow
of information needed to model nutrition orders in HL7 version 3.
6
Storyboard Sample Format
Storyboard Topic
The purpose of the story board is to illustrate the communication flow and documentation of a . . .
Storyboard Actors and Roles
Triage Nurse
Trauma Physician
Etc.
Pre-Condition
To be inserted
Sequence of Events, Storyboard, Activities
To be inserted
Post Condition
To be inserted.
7
Diet Order Storyboards and Use Cases
Use Case 1: Order New Diet—General/Healthful (unrestricted) Diet
Use Case Description
The purpose of this use case is to illustrate a physician or LIP ordering a diet in the patient record. This
diet order information needs to be shared with other care providers and hospital departments which
have specialized computer systems. Typically a physician will order a diet by selecting from a list of
diet modification codes defined at each hospital facility. The addition of a diet order is the trigger
event that will initiate meal service for a patient who is admitted to the hospital. The Food & Nutrition
Services department needs a diet order to notify them that a patient is able and allowed to eat. The
order should designate a start time or meal at which the new diet order is to take effect. This start
time may be a specific time (now or in the future) or meal. Upon receipt of the diet order information,
the Food & Nutrition Services operation will prepare and serve the patient diet-appropriate foods
according to the facility’s meal service policies. A diet order may have an expiration or end point time
such as a special diet needed for a specific test, but this is not common.
Conditions
This use case applies to the entry of any new diet order for a patient. The order should take effect at
the designated start time or meal specified in the order and should remain in effect until it is cancelled,
suspended, or superseded by a subsequent new diet order.
Preconditions
1. The patient has been admitted to an inpatient nursing unit of an acute care hospital
2. Admission nutrition screening has already been completed on the patient
3. The acute care hospital uses an electronic health record (EHR)
4. The acute care hospital uses CPOE
5. The acute care hospital uses an electronic food and nutrition management system (FNMS)
6. The acute care hospital EHR and FNMS share information via HL7 interface, either one-way or bidirectional.
8
7. The licensed entity (LIC) registered nurse (or Healthcare Provider (PROV-RN)), registered dietitian
or (Healthcare Provider (PROV-RD)) and the diet clerk all have access to the EHR. The diet clerk
(DC) and the registered dietitian also have access to the FNMS.
Actors/Roles
Aaron Attending (Attending Physician - LIC/Author)
Adam Everyman (Patient)
Nancy Nightingale (Registered Nurse - PROV-RN)
Connie Chow (Dietitian - PROV-RD)
Diet Clerk (Need a name to assign)
Foodservice Worker (Need a name to assign)
Use Case Sequence of Steps
1. Physician enters an order into CPOE system for a new diet selecting ‘General/Healthful’ diet code
for patient Adam Everyman that is to begin immediately.
2. The Diet Order is sent to Food & Nutrition Services via HL7-compliant interface to the department’s
food & nutrition management software system (FNMS).
3. FNMS automatically acknowledges the new diet order electronically (e.g., sends an ACK message to
the CPOE sending system) and the FNMS patient record for Adam Everyman is updated with the
new diet order details.
4. Food & Nutrition department prepares a meal tray with foods appropriate for the ordered diet for
the patient according to the facility’s meal service procedures, which may be at the next scheduled
meal service or for on-demand hotel-style meal delivery.
5. Meal tray is delivered to the patient.
Use Case Scenario
Adam Everyman, a 40-year old male with a fractured femur, is admitted to room 234 of GHH Inpatient
(orthopedic) Unit at Good Health Hospital at 16:30. Adam Everyman tells nurse Nancy Nightingale he
is hungry and wants to know when he can eat. Dr. Aaron Attending assesses the patient and
determines that he has no other medical conditions or complications at this time. Dr. Aaron Attending
enters a new diet order for a ‘General/Healthful’ diet without any therapeutic modifications to start
now (16:30) and to continue with no end date/time specified into the CPOE system of Good Health
Hospital. The diet order information is electronically transmitted to the Nutrition Services
department’s computerized food and nutrition management system (FNMS) which automatically
9
acknowledges receipt of the order transaction at 16:45 and updates the patient record for Adam
Everyman matching the diet code for ‘General/Healthful’ diet and sets that start time of that diet order
as of 16:30, which will allow Adam Everyman to receive a dinner meal tray. A diet clerk in the Nutrition
Services department uses the FNMS to generate tray tickets for dinner. Foodservice trayline workers
assemble a meal tray for Adam Everyman that includes food appropriate for General/Healthful dinner
meal. Adam Everyman receives his dinner meal tray according to the department’s meal service
delivery schedule.
10
Use Case 2: Order New Diet with Quantitative, Nutrient-based Modifications
Use Case Description
The purpose of this use case is to describe the flow of information that will initiate meal service for an
admitted patient who requires a diet with multiple quantitative nutrient modifications such as that
required for a diabetic patient undergoing renal dialysis treatment.
•
Example: 80 gm Protein + Consistent Carb + 2g Sodium + 2g Potassium + 800-1000 mg
Phosphorus + 1500 mL Fluid Restricted
Conditions
This use case applies to the entry of any new diet order for a patient requiring one or more diet
modifications that specify a quantity or range of a given nutrient. The order should take effect at the
designated start time or meal specified in the order and should remain in effect until it is cancelled,
suspended, or superseded by a subsequent new diet order.
Preconditions
Same as previously stated
Actors/Roles
Harold Hippocrates (Physician - Author)
Eve Everywoman (Patient)
Nancy Nightingale (PROV-RN)
Connie Chow - Dietitian (PROV-RD)
Diet Clerk
Foodservice Worker
Use Case Sequence of Steps
1. A patient with diabetes and chronic kidney disease (CKD) on dialysis (stage 5) is admitted to the
hospital with edema. The patient weighed 72 kg at admission.
2. Registered Dietitian (RD) completes a nutritional assessment documenting the patient’s usual
weight as 69 kg and a diet history that reveals that the patient’s typical food intake exceeds her
recommended sodium, and potassium levels and her carbohydrate intake varies considerably
contributing to uncontrolled blood glucose values. The RD calculates the patient’s protein needs
given her dialysis treatments, e.g., 1.2 grams protein/kg body weight, and recommends a protein
level diet of 80 gm protein/day. Protein level diets at Good Health Hospital are ordered in 10 gram
11
3.
4.
5.
6.
7.
increments, e.g., 60 gm pro, 70 gm pro, 80 gm pro, etc. The RD documents her nutrition
recommendations in the EHR.
After reviewing the RD’s recommendations, the physician enters a new diet order for 80 gm
protein + Consistent Carbohydrate + 2g sodium + 2g potassium + 800-1000mg Phosphorus + 1500
mL Fluid Restricted by selecting from the available diet codes in the CPOE system.
The diet order is sent to Food is sent to Food & Nutrition Services via HL7-compliant interface to
the department’s FNMS.
FNMS automatically acknowledges the new diet order electronically (e.g., sends an ACK message to
the CPOE sending system) and the FNMS inserts the new diet order details into the existing
admission record patient record for Eve Everywoman.
Food & Nutrition department prepares a meal tray with appropriate foods to ensure that nutrients
are within the prescribed quantities for the patient served according to the facility’s meal service
operation procedures.
Meal tray is delivered to the patient.
Use Case Scenario
Eve Everywoman, a patient with diabetes and chronic kidney disease requiring dialysis is admitted to
the hospital with an infection and edema. Eve’s usual weight is 69 kg and her admit weight was
recorded as 70.5 kg. Connie Chow, the registered dietitian, completes a nutritional assessment for Eve
including a diet history that reveals Eve has been eating foods high sodium and potassium while not
controlling her carbohydrate intake. Connie documents her assessment findings and nutrition
prescription recommendations in the EHR.
12
Use Case 3: Texture/Consistency Modifications
Use Case Description
The purpose of this use case is to notify a Food & Nutrition Services department of an order that
relates to resident/patient texture modification. Texture modification is part of the diet order, and
may have different textures ordered for different food groups, e.g., ground meat, or individual foods
for one resident/patient. In addition, texture modification could include snacks and meals at different
consistencies recommended by the Speech and Language Pathologist (SLP) and/or the physician which
must be communicated to the Food & Nutrition Services department or resident/patient care staff.
Preconditions
1. The patient has been transferred from a nursing home and is admitted to an inpatient nursing unit
of an acute care hospital
2. Admission nutrition screening has already been completed on the patient
3. The acute care hospital uses an electronic health record (EHR)
4. The acute care hospital does not have a CPOE.
5. The acute care hospital uses an electronic food and nutrition management system (FNMS)
6. The acute care hospital EHR and FNMS share information via HL7 interface, either one-way or bidirectional.
Use Case Sequence of Steps
1. Resident/Patient swallowing status warrants a texture modification per the recommendations of
the Speech/Language Pathologist.
2. The Speech/Language Pathologist per protocol writes an order for Puree diet. Since this particular
order is not for a specific day or meal, it applies to all days and meals. Note: For multiple texture
modifications for one resident/patient the SLP or authorized provider may write orders designating
that the modification is for certain days, meals, or specific food groups/foods.
3. The written order is transcribed and entered into the EHR
4. Puree order is sent to Food & Nutrition Services via HL7-compliant interface to the department’s
food & nutrition management software system.
5. Once in the Resident’s/patient’s record, any tray ticket or snack/nourishment label printed from
the FNSM for that patient will print with Puree listed.
13
Actors
Adam Everyman (Patient)
Harold Hippocrates (Physician)
Nancy Nightingale (Registered Nurse)
Ellen Enter (Transcriptionist)
Foodservice Staff Worker (need name)
Texture Modifications
Adam Everyman has been diagnosed with a Transient Ischemic Attack (TIA). Dr. Harold Hippocrates
writes an order for a Puree diet based on the recommendations of Speech Pathologist. Ellen Enter
transcribes the order into appropriate EHR screen where she selects Puree from a distinct drop-down
menu of Diet - Texture Modification options. When prompted for respective Days or Meals, Anne
enters ALL and ALL, since this order is not unique to a particular day or meal. Alternatively this could
be entered to begin now (0800) with no end or expire date-time. Once entered, this order is sent via
interface to the Food & Nutrition Services department’s nutrition management software system where
it automatically populates the appropriate area of the resident/patient record within that software
system.
As the next meal approaches, Joe Foodservice Worker executes functions in the department’s software
system that produces tray tickets for that meal. Smith Patient’s tray ticket prints with Puree the
designated area of the tray ticket. Joe’s co-workers who assemble resident/patient trays immediately
recognize that this order means that only puree items are to be served on the resident’s/patient’s tray.
14
Use Case 4: Diet Order change to ‘NPO for Tests’
Use Case Description
The purpose of this use case is to describe the situation where a patient’s diet order must be changed
to ‘NPO’ to indicate that the patient is not allowed to eat or drink anything for a specified period of
time in preparation for medical tests that will be conducted. For patient safety reasons, this scenario
relies on entry of a separate, new diet order once the tests are completed indicating to foodservice
that the patient may resume eating rather than modeling this using an order with an explicit expire
time or suspending/holding the previous diet order.
Use Case Sequence of Steps
1. Admitted patient, Adam Everyman, is transferred to the cardiac unit of the hospital and has an
active diet order for a ‘General/Healthful’ diet
2. Doctor orders lab tests (e.g., Lipid Profile) for tomorrow at 0600 that require an 8-hour fast.
Doctor changes the diet to ‘NPO for tests’ diet to be effective from 2200 after the evening meal
service. He also authorizes nursing to enter a new order diet order to resume the ‘General/Normal’
diet after tests are completed.
Orders are transmitted to FNMS of the Nutrition Services Department.
3. FNMS automatically acknowledges the new diet order electronically (e.g., sends an ACK message to
the CPOE sending system) and the FNMS patient record for Adam Everyman is updated with the
new diet order details.
4. The patient receives a meal service tray with appropriate foods according to the hospitals meal
service policies for the evening (dinner) meal.
5. The patient is not allowed to order any additional food or beverages after 2200 hours per the ‘NPO
for Tests’ diet order.
6. In the morning, the blood draw for the lab is delayed, so the patient should not be allowed to order
food until that is completed and the new diet order is sent. This is one reason food and nutrition
professionals responsible for patient meal do not want order to have a set expire time as many
15
7. Patient’s blood is drawn by the lab tech at 0735 and the patient is hungry, so per the physician’s
authorization the nurse enters a new diet order to resume the ‘General/Healthful’ diet effective
immediately.
8. FNMS receives the new diet order for ‘General/Healthful’ diet so the patient is once again allowed
to order/receive meals.
9. Nutrition Services department prepares and delivers a breakfast tray to the patient.
16
Use Case 5: Pediatric Specialty Orders – NEED TO DOCUMENT
Use Case Description
The purpose of this use case is to describe the information required for typical pediatric diet orders.
Such orders will include orders for breast feeding and infant formulas including any necessary additives
or fortifiers.
Components of an infant formula order:
Infant formula and/or fortified breastmilk orders are placed by the physician or dietitian based upon
the nutrient and caloric density required by infant. The caloric concentration of standard
manufacturer infant formulas is 20 kcal/oz (0.67 kcal/mL). Hospitalized infants often require higher
caloric concentrations, so formulas are mixed using high-calorie concentrated liquids (40 kcal/oz or
1.33 kcal/mL) or high-calorie ready-to-feed (22- or 24-kcal/oz) formulas to prepare the total volume of
formula required.

Base Formula Product by caloric density in kcal/oz (US/Canada) or kcal/30mL (Australia/Canada) or
kJoules/30mL(Australia) (Need to verify this with international representatives)
o Standard caloric densities – 20 kcal/oz (kcal/30mL), 22, 24, 26, 27, & 30
 ProductA, 24 kcal/oz
 Modular Additives – Additional components may be mixed with the base formula in specific
amounts or to add a certain number of kcals, carbohydrate, protein, and/or fat, such as “plus
Glucose Additive to 27 kcals/oz.”
 Carbohydrate Additive (Liquid or Powder - 2 kcal/mL)
 Total caloric density (sum of base + additives) in kcals or kJoules per oz or 30mL or 100 mL
 To total of 27 kcal/oz
 Feeding frequency – e.g. every 3 hours or 8 feedings/day
 Volume per feeding – 3 oz (90 mL)
o Total volume of feeding required per day – 24 oz (720 mL)
Infant Formula Example:
Formula Product A (24 kcal/oz) + CHO Additive = 27 kcal/oz
60 mL x 7 feedings/day
17
Conditions
Preconditions
Same as previously stated
Actors/Roles
Karen Kiddler (Pediatrician)
Kari Kidd (Patient)
Nancy Nightingale (PROV-RN)
Connie Chow - Dietitian (PROV-RD)
Formula Room Technician
Use Case Sequence of Steps
Use Case Scenario
Karen Kidd is a 2-week old infant in the Neonatal Intensive Care Unit (NICU) at Good Health Hospital.
18
Use Case 6: Order Oral Nutritional Supplement
Use Case Description
The purpose of this use case is to notify a Food & Nutrition Services department of an order that
relates to the provision of an oral nutritional supplement.
Conditions
This use case applies to oral beverage supplements including commercial products which are often
vitamin/mineral modified and house-made preparations such as shakes made from milk and ice cream
products. Specifications may be by name or by desired nutrient composition. Use of a supplement
may be in addition to other diet orders or be the sole source of oral nutrient intake.
Exclusions
This use case does not include use of commercial or house-made supplements for tube-feedings.
Products used may be identical, but this use case will only address those for oral consumption. The use
case does not address herbal or encapsulated dietary supplements dispensed by pharmacy or brought
by patients from home.
Preconditions
1. The patient has been admitted to an inpatient nursing unit of an acute care hospital
2. Admission nutrition screening has already been completed on the patient
3. The acute care hospital uses an electronic health record (EHR)
4. The acute care hospital uses CPOE
5. The acute care hospital uses an electronic food and nutrition management system (FNMS)
6. The acute care hospital EHR and FNMS share information via a one-way or bi-directional interface.
7. The licensed entity (LIC) registered nurse (or Healthcare Provider (PROV-RN)) and registered
dietitian or (Healthcare Provider (PROV-RD)) have access to the EHR. The diet clerk (DC) and the
registered dietitian have access to the FNMS.
Actors/Roles
Rachel Resident (Physician - Author)
Connie Chow (Dietitian – PROV(RD)
Nancy Nightingale – (Registered Nurse - PROV(RN)
19
Adam Everyman (Patient – PAT)
DC – Chris Clerk (?role code for non-providers)
SDLOC – service delivery location
Use Case Sequence of Steps
1. Trigger: Patient requires additional source of calories/protein/carbohydrate/fat.
2. LIC (role) enters supplement (entity) as medical order (act) into EHR
a. (Alternative) RN or RD enter medical order into EHR and LIP countersigns order
b. (Alternative) RN or RD enter service order into EHR
3. Order sent to FNMS via interface
a. PAT role
b. Service location role
c. Act – diet code based on quantity, status, timing
d. Entity – general statement about the supplement, material state
4. Order received and fulfilled by DC in FNMS
5. Order fulfillment sent by FNMS to EHR
6. Order resulted in EHR
7. PAT receives supplement
8. Alternate act states for cancellation, suspension
Use Case Scenario
Adam Everyman is admitted to Good Health Hospital with second degree burns. A high-calorie diet is
ordered but the RD notes that the patient is still not consuming adequate calories. The RD confers
with the LIP and they agree that a liquid oral supplement should be provided to Adam Everyman.
The LIC enters a supplement order into the EHR. The order contains the following information:
1.
2.
3.
4.
5.
6.
The patient name
The patient identifier
Prescriber
Patient location
Date/Time of order
The name of the supplement (commercial canned or house-made) or the desired
nutrient composition of the supplement
7. Start Date/Stop Date
8. Start Time/Stop Time or meal/nourishment association
9. Quantity per administration
20
The order is then electronically passed from the EHR to the FNMS. The FNMS acknowledges receipt of
the order. The FNMS places the new order information into its patient record. The RD (or DC) reviews
the order to ensure it is accurate and appropriate, or the FNMS has the ability to determine if the
supplement is appropriate based on other diet orders. The DC then utilizes the FNMS to issue the
desired supplement from inventory (or preparation instructions) and a delivery ticket to accompany
the supplement to the patient location. Once a delivery ticket is generated,, the FNMS then returns an
electronic message to the EHR to result the order with the following information:
1.
2.
3.
4.
The patient name
The patient identifier
Date/Time of order fulfillment
The name of the supplement provided
Adam Everyman receives his supplement.
21
Use Case 7: Order Enteral Nutrition (Tube Feeding)
Use Case Description
The purpose of this use case is to notify a Food & Nutrition Services department that a patient requires
an enteral tube feeding. ASPEN (American Society for Enteral and Parenteral Nutrition) defines
“enteral nutrition” as “nutrition provided through the gastrointestinal tract via a tube, catheter, or
stoma that delivers nutrients distal to the oral cavity.” Best practices for enteral nutrition (EN) orders
recommend that all of the following are documented in the EN order request: (1) patient
identifiers/demographics including age and weight, (2) formula and/or modular components required
to meet the patient’s specific nutritional needs, (3) identification of enteral access delivery site and
device (route and access), and (4) administration method and rate.
Conditions
This use case applies to enteral or tube feeding orders that require one or more products, whether
commercially pre-prepared formula or mixed on site to include modular components, for
administration through an enteral access device which is defined as a “tube placed directly into the
gastrointestinal tract for the delivery of nutrients or drugs” (ASPEN Enteral Nutrition Practice
Recommendations, JPEN 2009). Use of a tube feeding may be in addition to an oral diet order and/or
total parenteral nutrition; or EN may be the sole source of nutrient intake for an individual unable to
consume food or beverages by mouth.
Exclusions
This use case does not include nutritional supplements that a person would consume orally although
some products used for enteral/tube feeding formulas are also suitable as oral supplements; nor does
it include parenteral nutrition orders that require intravenous administration of nutrients. Note:
Infant enteral formulas are a special sub-case of this main enteral nutrition order use case (to be added
later).
Preconditions
1. The patient has been admitted to an inpatient nursing unit of an acute care hospital
2. Patient has had an enteral access device (tube) successfully placed and has been assessed and
deemed ready to initiate enteral feedings
22
3. The acute care hospital has established a formulary of available enteral formulas specific to the
institution based upon patient population needs
4. The acute care hospital uses an electronic health record (EHR)
5. The acute care hospital uses CPOE (Computerized Provider Order Entry)
6. The acute care hospital uses an electronic food and nutrition management system (FNMS)
7. The acute care hospital EHR and FNMS share information via HL7-compliant interfaces
8. The licensed entity (LIC) registered nurse (or Healthcare Provider (PROV-RN)) and registered
dietitian/nutrition support specialist or (Healthcare Provider (PROV-RD)) have access to the EHR.
The Formula Room Technician (FT) and the registered dietitian have access to the FNMS..
Actors/Roles with class codes
Aaron Attending (Physician - LIC)
Connie Chow (Registered Dietitian/Nutrition Support Specialist - PROV (RD))
Nancy Nightingale (Registered Nurse - PROV(RN))
Adam Everyman (Patient - PAT)
FT – Francis Tech (What is the name and role code for non-providers?)
SDLOC – service delivery location (patient’s admit location – unit-room-bed)
Use Case Sequence of Steps – New Enteral Nutrition Order
1. Enteral access device (Nasogastric tube) placement is confirmed and patient is assessed and ready to begin
enteral nutrition feeding. (Pre-condition)
2. LIC (role) enters the enteral nutrition order (entity) as medical order (act) into CPOE/EHR
a. LIP (or LIC as used her) would enter directly into EHR
b. RN or RD/CNSD enter medical order into EHR as per hospital policy
3. EN order sent electronically to FNMS via interface
a. PAT role
b. Service location role
c. Entity –
d. Act – status, timing, data about the entity
i. Mood – Request (RQO))
e. Act Class – Substance Administration
4. Order is received by FNMS and order receipt is acknowledged
a. FNMS needs to correlate this EN tube feeding order with the medical diet order (Note: The FNMS
needs to be notified if this patient is to receive solely tube feedings or whether he also requires food;
this needs to be communicated in conjunction with diet order information.)
23
5. FNMS user (Formula Room Technician) prepares or assembles the required enteral products for delivery to
the patient’s unit (service delivery location). FNMS generates patient-specific labels as required.
6. Enteral products for this patient are delivered to the unit to fulfill this order.
7. Upon receipt of proper formula and at the designated order start time, PROV-RN (role) begins the enteral
feeding at the initial rate.
8. Initiation of EN is documented in the EHR.
9. PROV-RN advances feedings (rate and/or volume increases) as directed by the EN order protocol and
documents each increase in EHR and any signs of feeding complications.
a. (Is this Substance Admin or Observation?)
10. Adjustments to various components (rate, formula, etc) of enteral nutrition orders are very common as
patients may experience complications or may not fully tolerate the feedings.
Use Case Scenario
Adam Everyman, a 55-year old male motor vehicle accident victim with multiple rib fractures, major
lung contusions and haemothorax that has been drained is admitted to the Intensive Care Unit of Good
Health Hospital from the Emergency Department for ventilator support. A nasogastric enteral access
device has been placed and radiograph (X-ray) has confirmed proper placement. The patient has been
assessed is now haemodynamically stable enough to begin enteral nutrition feedings while he awaits
further surgery. After consultation with the nutrition support dietitian, a standard, polymeric enteral
formula was selected from the hospital’s established formulary and a total energy target of 20-25
kcal/kg body actual weight with 1.2 – 1.5 grams protein/kg ideal body weight has been set. Aaron
Attending designates a diet order of NPO (no oral food intake) and the following enteral nutrition order
using City Hospital’s EN order set protocol that directs advancement of the feedings from initiation to
the target goal rate within the CPOE system (see sample Adult EN Order Form):
Name: Thomas Trauma
MRN: 00999 DOB: 1/9/1956
Room: ICU – 10
Dosing Weight: 83.2 kg
Formula: Standard*
Delivery Site
* Could be generic description of types or product-specific e.g., Osomolite
Route: Gastric
Access: Nasogastric
Method of Administration: Pump-assisted
Rate:_20__Initial mL/hour Advance by: 10 mL/hour every _4_hour(s) to goal of 70 mL/h
Order Start Date/Time: 20110109 @ 1400
The NPO diet and EN orders are received electronically in the FNMS. Francis Technician verifies the
orders received in the FNMS. She prepares and labels the required amount of enteral formula
24
products for transport to the unit. Upon receipt of the product at the unit, Nancy Nurse verifies the
formula against the enteral nutrition orders and starts the tube feeding at the initial rate of 20
mL/hour following normal administration protocols (sterile water for flushing the tube, elevated head
of bed, etc.) recording the date and time the formula is spiked/hung on the product label and in the
EHR. After 4 hours if there are no observed feeding complications or contraindications, Nancy Nurse
will increase the pump rate to 30 mL/hour and continue that process over the next 24 hours until the
goal rate is achieved or the EN orders are modified.
25
Use Case 8: Meal/Special Service Designation Order
(Note: Needs work – need to revise actor names and abbreviations and put into above format.)
Use Case Description
The purpose of this use case is to notify a Food & Nutrition Services department of an order that
relates to patient tray delivery. As opposed to a diet order, a Meal/Special Service Designation is a
message either about delivery time (eg, Hold Tray, Late Tray, Early Tray), adaptive equipment (eg,
Built-up Spoon, Plate Guard), staff assistance (eg, Cut Up Meat, Open Cartons), or isolation precautions
(eg, Isolation Tray, Disposable Dishes). In addition, a Meal/Special Service designation could include
messages such as Tray to Nurse’s Station, VIP, Suicide Precautions, or any other messaging relevant to
and desired by the Food & Nutrition Services department or patient care staff.
Use Case Sequence of Steps
1. Patient’s diagnosis warrants isolation precautions; physician writes/enters order for Isolation Tray.
2. Since this particular order is not for a specific day or meal, ALL is selected for Days and Meals.
3. Isolation Tray order is sent to Food & Nutrition Services, either via HL7-compliant interface to the
department’s food & nutrition management software system, or via a printout in the department.
4. Once in the patient’s record, any tray ticket or snack/nourishment label for that patient will print
with Isolation Tray listed.
For sensitive messages (eg, Suicide Precautions), rather than printing on the patient’s tray ticket as
such, either a departmentally-defined code could be used (eg, ******) or the particular services could
be set to not print on the tray ticket. Staff could instead obtain a list of respective patients via an ondemand report and adjust trays accordingly.
Actors
Prescott Patient
Daniel Doctor
Uma Unit Secretary
Frank Foodservice Staff Worker
26
Use Case Scenario for Meal/Special Service Designation
Prescott Patient has been diagnosed with H1N1 influenza. Daniel Doctor gives a verbal order for
Isolation Tray (Disposable Dishes) to Uma Unit Secretary. Uma Unit Secretary proceeds to the
appropriate EHR screen where she selects Isolation Tray from a distinct drop-down menu of
Meal/Special Service options. When prompted for respective Days or Meals, Uma enters ALL and ALL,
since this order is not unique to a particular day or meal (as opposed to, for example, Early Tray for
tonight’s dinner only). Once entered, this order is sent via interface to the Food & Nutrition Services
department’s nutrition management software system where it automatically populates the
appropriate area of the patient record within that software system.
As the next meal approaches, Frank Foodservice Worker executes functions in the department’s
software system that produce tray tickets for that meal. Prescott Patient’s tray ticket prints with
Isolation Tray in large font in the designated area of the tray ticket. Frank’s co-workers who assemble
patient trays immediately recognize that this order means that only paper or plastic dishes and utensils
are to be used for this patient’s tray.
Prescott Patient is served his tray on entirely disposable materials. After Prescott finishes consumption
of his meal, the staff member discards the entire tray and all its contents.
27
Use Case 9: Request RD/Nutrition Consult
Use Case Description
The purpose of this use case is to place an order for a dietitian to consult on a hospital inpatient and
the subsequent fulfillment of that order request.
Summary:
1. LIC instantiates dietitian consultation order in the EHR.
2. Order is communicated to RD directly via EHR reports/alerts as well as via an interface to the
FNMS.
3. RD receives order, completes requested service and documents service.
Actors/Roles with class codes
LIC – Daniel Doctor
PROV-RD (Registered Dietitian/Nutritionist Healthcare Provider)
Hospital Unit Clerk (Data Entry)
Preconditions:
1. The patient has been admitted to an inpatient nursing unit of an acute care hospital
2. A need for RD consultation is determined by the LIC
3. The RD is authorized to provide all nutrition-related consultation services requested by the LIC
4. Nutrition-related consultation services include, but are not limited to: Patient nutrition
assessment, follow-up evaluation, education assessment, patient counseling, patient education,
discharge assessment, calorie count, TPN order recommendation, enteral feeding
recommendation.
5. Admission nutrition screening has already been completed on the patient
6. The acute care hospital uses a electronic medical record or EHR.
7. The acute care hospital also uses an EOS
8. The LIC, RD and HUC are authorized users of the EOS
28
9. The acute care hospital also uses an EDS
10. The LIC, RD and HUC are authorized users of the EDS
11. The acute care hospitals EDS and EOS share information via a bi-directional interface (or may be
integrated as one EHR).
12. The acute care hospital does not use CPOE
Glossary:
Term
Definition
AF1
Alternate Flow 1
AF2
Alternate Flow 2
AF3
Alternate Flow 3
Communication Device: A regular telephone, cellular phone, pager, radio, or
CD
other communication hardware by which one individual communicates a
message to another individual verbally or using readable text.
Communication Output: A record by which the results of communication from
one individual can be viewed by another individual. May include, but is not
CO
limited to: Automated computer print-out, computer report viewed on print
output or on-screen, or paper message delivered by hand/pneumatic tube
system or other means.
CPOE
Computerized Physician Order Entry
EDS
Electronic Documentation System
EHR
Electronic Health Record
EOS
Electronic Ordering System
HUC
Hospital nursing Unit Clerk
LIC
Licensed Independent Practitioner: Physician, Physician Assistant, Nurse
Practitioner, or other licensed individual authorized to place patient orders.
NSD
Nutrition Services Department
PMR
Paper Medical Record
RD
Registered Dietitian
29
RDCO
Registered Dietitian Consult Order
TPN
Total Parenteral Nutrition
Basic Flow:
Line
1
2
Actor Action
System Response
LIC writes order in PMR for RDCO
In reviewing PMR for orders, HUC finds
RDCO.
3
HUC logs into EOS
HUC log-in authenticated
4
HUC enters RDCO into EOS
EOS confirms entry of RDCO
5
HUC initials PMR to affirm that RDCO
has been processed.
6
NDS receives RDCO via CO
7
NDS communicates RDCO to RD via CD
8
RD receives RDCO
9
RD completes requested service(s)
10
RD logs into EDS
11
RD selects patient for whom service(s)
was/were provided.
RD log-in authenticated
EDS displays appropriate patient
EDS prompts RD to affirm that
12
RD documents service(s) provided
documentation is correct and to
electronically sign documentation.
RD clicks on appropriate button to
13
affirm electronic signature for
EDS confirms signed documentation
documentation.
14
15
EDS communicates completed RDCO to EOS
RD signs out of EDS
Post Conditions:
30

The requested service for the patient has been completed and the nutrition staff takes
this service into consideration in planning for any additional care for the patient.
Alternate Flows:
AF1 – EHR with Full CPOE
Preconditions:
1. Assume basic flow preconditions # 1-5
2. Acute care hospital has EHR with fully functioning CPOE
3. The LIC, RD and HUC are authorized users of the EHR
Line
System Actor Action
System Response
1
LIC logs into EHR
LIP log-in authenticated
2
LIC selects appropriate patient
EHR displays appropriate patient
3
LIC enters RDCO
EHR confirms entry of RDCO
EHR automatically communicates RDCO to
4
RD via CD.
5
RD receives RDCO
6
RD completes requested service(s)
7
RD logs into EHR
8
RD selects patient for whom service(s)
was/were provided.
RD log-in authenticated
EHR displays appropriate patient
EHR prompts RD to affirm that
9
RD documents service(s) provided
documentation is correct and to
electronically sign documentation.
RD clicks on appropriate button to
10
affirm electronic signature for
EHR confirms signed documentation
documentation.
11
RD signs out of EHR
Post Conditions:
31

The requested service for the patient has been completed and the nutrition staff takes
this service into consideration in planning for any additional care for the patient.
AF2 – EHR + Order Set
Preconditions:
1. Assume basic flow preconditions # 1-6
2. Acute care hospital has EHR with CPOE that generates printed order sets
3. The LIC, RD and HUC are authorized users of the EHR
Line
System Actor Action
System Response
1
LIC logs into EHR
LIP log-in authenticated
2
LIC selects appropriate patient
EHR displays appropriate patient
3
LIC enters RDCO
EHR confirms entry of RDCO
4
EHR prints copy of order set
5
LIC logs out of EHR
6
LIC places order set in PMR
7
In reviewing PMR for orders, HUC finds
RDCO.
8
HUC logs into EHR
HUC log-in authenticated
9
HUC enters RDCO into EHR
EHR confirms entry of RDCO
EHR automatically communicates RDCO to
10
11
RD via CD.
HUC initials PMR to affirm that RDCO
has been processed.
12
RD receives RDCO
13
RD completes requested service(s)
14
RD logs into EHR
15
RD selects patient for whom service(s)
was/were provided.
RD log-in authenticated
EHR displays appropriate patient
32
EHR prompts RD to affirm that
16
RD documents service(s) provided
documentation is correct and to
electronically sign documentation.
RD clicks on appropriate button to
17
affirm electronic signature for
EHR confirms signed documentation
documentation.
18
RD signs out of EHR
Post Conditions:

The requested service for the patient has been completed and the nutrition staff takes
this service into consideration in planning for any additional care for the patient.
AF3 – Simple PMR
Preconditions:
1. Assume basic flow preconditions # 1-6
Line
1
2
3
4
System Actor Action
System Response
LIC writes order in PMR for RDCO
In reviewing PMR for orders, HUC finds
RDCO.
HUC communicates RDCO to NDS via
CO or CD.
HUC initials PMR to affirm that RDCO
has been processed.
5
NDS receives RDCO via CO
6
NDS communicates RDCO to RD via CD
7
RD receives RDCO
8
RD completes requested service(s)
9
RD documents service(s) provided;
33
signs and dates documentation.
Post Conditions:

The requested service for the patient has been completed and the nutrition staff takes
this service into consideration in planning for any additional care for the patient.
Questions:

What other use cases are connected to the RDCO? The calorie count service requires interim
work by diet technicians, nursing or others before the RD can document completion.

The TPN recommendation service requires assessment and calculation work on the part of the
dietitian as well as possible collaboration with pharmacy.

How many additional alternate flows are possible? Only 4 variations are shown in order to
highlight some of the most common situations, however numerous iterations are possible
based on the combination of systems and work flows available in different hospitals.

How would other task list, messaging and alerting functionality of systems affect the use case?
Many EHR’s available today offer more sophisticated work flow processing with these tools.
Story Board:
-
Provider writes order for dietitian consult in paper medical record; signature and date/time written
by provider.
34
-
While processing new patient orders from the paper medical record, unit clerk finds the dietitian
consult order, enters it in the ordering section of the electronic health record (EHR) and initials the
order in the paper medical record.
-
The dietitian consult order is communicated through the EHR to the Nutrition Services Department
(print out, page, text message to cell, periodically printed report).
-
The Nutrition Services Department contacts the dietitian responsible for the patient on which the
order was placed and communicates the details of the consult order.
-
The dietitian completes the requested service, and then documents the care in the EHR with
appropriate signature, date and time.
35
Sequence and Activity Diagrams
DIET ORDER SEQUENCE
MD diet order,
supplements, RD
consult, VO orders,
assigns magmt of
TPN or TF others
CPOE or paper
chart
EMR
NURSING Order flavor of
supplement, VO orders hold
diet for test, allergies, late or
early tray
Dietitian input
Limited access for
VO or clinical
privileges
Limited access for
info
HL7 interface
Documentation of
care plan, educ. And
order labs, TPN and
adjusts electrolytes
FNMS
FOOD & NUTRITION
MGT SYS
Diet Clerk food
preferences,
allergies,
intolerances;
notifies diet
consult, corrects
diet order errors;
inputs
nourishment
requests
Diet Supplement Flow Chart
Electronic Health Record
ORDER Supplement
1000 Calories per Day
PAT Role, Service
location, Diet Code,
Entity
Food and Nutrition
Management System
LIC
Order Received and Approved
by Provider or Diet Clerk
PROV
Order
Resulted
PAT
Order fulfilled with available
supplement that meets criteria
Supplement Provided to
Patient
36
Glossary
(Need to merge with existing HL7 Glossary + EHR Functional Model + Nutrition CME sources)
Diet – (V3) A supply Act dealing specifically with the feeding or nourishment of a subject. The detail of
the diet is given as a description of the Material associated via Participation.typeCode = “product”.
Medically relevant diet types may be communicated in Diet.Code, however, the detail of the food
supplied and the various combinations of dishes should be communicated as Material instances.
Examples – gluten free, low sodium.
From HL7 Glossary: A diet consists of the diet codes, supplements, and preferences effective at a given
time. These three specifications govern which foods a patient will receive. Diets generally do not have
a stated ending time to ensure that the patient always receives food.
Diet Code - A diet code defines which foods a patient may receive; a patient must have at least one
diet code to receive food.
Dietary Orders - An order for a patient diet. A patient may have only one effective dietorder at a time.
Diet.energyQuantity (PQ): deprecated concept. Convey quantity using a content relationship with an
attribute expressing “calories”. The physical quantity SHOULD be convertible to 1 kcal/d (or 1 kJ/d).
Diet.carbohydrateQuantity (PQ): express content relationship to an entity with a code of
“carbohydrate” and a quantity attribute on the content relationship e.g. the supplied amount of
carbohydrates per day. Convey carbohydrate restriction in the carbohydrateQuantity. Use case in
grams, but not constrained to this unit of measure.
EHR – Electronic Health Record: A comprehensive, structured set of clinical, demographic,
environmental, social, and financial data and information in electronic form, documenting the health
care given to a single individual.(ASTM E1769, 1995) Various, including DC.1
Material (MAT): A subtype of Entity that is inanimate and locationally independent. Example – food.
ODS - (New with Version 2.2) Dietary orders, supplements and preferences segment.
ODT - (New with Version 2.2) Diet tray instructions segment.
OMD - Dietary order message.
ORD - Dietary order - General order acknowledgement message
Order - An order is a request for a service from one application to a second application. The second
application may in some cases be the same, i.e., an application is allowed to place orders with itself.
Usually orders are associated with a particular patient.
Order Detail Segment - One of several segments that can carry order information. Examples are OBR
and RXO
Supply (SPLY): provision of a material by one entity to another. Provide Material class
Trigger Event The event that initiates an exchange of messages is called a trigger event. The HL7
Standard is written from the assumption that an event in the real world of health care creates the need
for data to flow among systems. The real-world event is called the trigger event. For example, the
trigger event “a patient is admitted” may cause the need for data about that patient to be sent to a
number of other systems. There is a one-to-many relationship between message types and trigger
event codes. The same trigger event code may not be associated with more than one message.
37
38
References and Acronyms
HL7 Healthcare Development Framework Version 1.5 Release 1
Acronym
Meaning
EHR
Electronic Health Record
EMR
Electronic Medical Record
HDF
HL7 Development Framework
PHR
Personal Health Record
Note
The HL7 development methodology
39
Appendix: Storyboard naming standards
Table 5: Patient Information for Storyboards
Cast
Family
Given
MI
Gender
SSN
patient, female
Everywoman
Eve
E
F
444-22-2
patient, male
Everyman
Adam
A
M
444-33-3
patient, child
Kidd
Kari
K
F
444-55-5
family, daughter
Nuclear
Nancy
D
F
444-11-4
family, husband
Nuclear
Neville
H
M
444-11-1
family, son
Nuclear
Ned
S
M
444-11-3
family, wife
Nuclear
Nelda
W
F
444-11-2
next of kin (parent)
Mum
Martha
M
F
444-66-6
next of kin (child)
Sons
Stuart
S
M
444-77-7
next of kin (spouse)
Betterhalf
Boris
B
M
444-88-8
next of kin (other)
Relative
Ralph
R
M
444-99-9
contact person
Contact
Carrie
C
F
555-22-2
Cast
Family
Given
MI
Gender
SSN
healthcare provider
Seven
Henry
L
M
333-33-3
assigned practitioner
Assigned
Amanda
A
F
333-44-4
physician
Hippocrates
Harold
H
M
444-44-4
primary care physician
Primary
Patricia
P
F
555-55-5
admitting physician
Admit
Alan
A
M
666-66-6
attending physician
Attend
Aaron
A
M
777-77-7
referring physician
Sender
Sam
S
M
888-88-8
intern
Intern
Irving
I
M
888-22-2
resident
Resident
Rachel
R
F
888-33-3
chief of staff
Leader
Linda
L
F
888-44-4
authenticator
Verify
Virgil
V
M
999-99-9
specialist
Specialize
Sara
S
F
222-33-3
allergist/immunologist
Reaction
Ramsey
R
M
222-22-3
anesthesiologist
Sleeper
Sally
S
F
222-66-6
Table 6: Healthcare Staff for Storyboards
HL7 Version 3 Domain Analysis Model: Diet and Nutrition Orders
Draft Release 1.0 – Use Cases and Storyboards
January 2010 WGM
Page 40
HL7 Version 3 Diet Orders 41
Cast
Family
Given
MI
Gender
SSN
cardiologist
Pump
Patrick
P
M
222-33-4
cardiovascular surgeon
Valve
Vera
V
F
222-33-5
dermatologist
Scratch
Sophie
S
F
222-33-6
emergency medicine specialist
Emergency
Eric
E
M
222-33-7
endocrinologist
Hormone
Horace
H
M
222-33-8
family practitioner
Family
Fay
F
F
222-33-9
gastroenterologist
Tum
Tony
T
M
222-44-2
geriatrician
Sage
Stanley
S
M
222-44-3
hematologist
Bleeder
Boris
B
M
222-44-3
infectious disease specialist
Pasteur
Paula
P
F
222-44-5
internist
Osler
Otto
O
M
222-44-6
nephrologist
Renal
Rory
R
M
222-44-7
neurologist
Brain
Barry
B
M
222-44-8
neurosurgeon
Cranium
Carol
C
F
222-44-9
OB/GYN
Fem
Flora
F
F
222-55-2
oncologist
Tumor
Trudy
T
F
222-55-3
ophthalmologist
Vision
Victor
V
M
222-55-4
orthopedic surgeon
Carpenter
Calvin
C
M
222-55-5
otolaryngologist (ENT)
Rhino
Rick
R
M
222-55-6
pathologist
Slide
Stan
S
M
222-44-4
pediatrician
Kidder
Karen
K
F
222-55-7
plastic surgeon
Hollywood
Heddie
H
F
222-55-8
psychiatrist
Shrink
Serena
S
F
222-55-9
pulmonologist
Puffer
Penny
P
F
222-66-2
radiologist
Curie
Christine
C
F
222-55-5
rheumatologist
Joint
Jeffrey
J
M
222-66-3
surgeon
Cutter
Carl
C
M
222-77-7
urologist
Plumber
Peter
P
M
222-66-4
physician assistant
Helper
Horace
H
M
222-66-5
registered nurse
Nightingale
Nancy
N
F
222-88-8
nursing assistant
Barton
Clarence
C
M
222-99-9
chiropractor
Bender
Bob
B
M
222-66-6
HL7 Version 3 Diet Orders 42
Cast
Family
Given
MI
Gender
SSN
dentist
Chopper
Charlie
C
M
222-66-7
orthodontist
Brace
Ben
B
M
222-66-8
optometrist
Specs
Sylvia
S
F
222-66-9
pharmacist
Script
Susan
S
F
333-22-2
podiatrist
Bunion
Paul
B
M
222-77-2
psychologist
Listener
Larry
L
M
222-77-3
lab technician
Beaker
Bill
B
M
333-44-4
dietician
Chow
Connie
C
F
333-55-5
social worker
Helper
Helen
H
F
333-66-6
occupational therapist
Player
Pamela
P
F
222-77-6
physical therapist
Stretcher
Seth
S
M
222-77-8
transcriptionist
Enter
Ellen
E
F
333-77-7
Pastoral Care Director
Sacerdotal
Senior
S
M
333-77-7
Chaplain
Padre
Peter
P
M
333-77-7
Informal Career
Comrade
Connor
C
M
333-77-7
Electrophysiologist
Electrode
Ed
E
M
333-77-7
Laboratory Specimen Processor
Spinner
Sam
S
M
333-45-4
IT System Administrator
Admin
I.
T.
M
333-33-3
Table 7: Organizations for Storyboards
HL7 Version 3 Diet Orders 43
Organizational Roles
Role
Name
Phone
Address
City
State
healthcare provider organization
Level Seven
555-555-
4444
Ann Arbor
MI
Healthcare, Inc.
3001
Healthcare
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Drive
healthcare insurer #1
healthcare insurer #2
employer
Health Authority
HC Payor, Inc.
Uare Insured, Inc.
Work Is Fun, Inc.
555-555-
5555 Insurers
3002
Circle
555-555-
8888 Insurers
3015
Circle
555-555-
6666 Worker
3003
Loop
555-555-
22 Wordy Way
Ann Arbor
MI
Health Authority
West
terminology provider
Titan Terminology
3099
Table 8: Facilities for Storyboards
Role
Name
Phone
Address
City
State
healthcare provider
Community Health
555-555-
1000 Enterprise
Ann Arbor
MI
and Hospitals
5000
Blvd
Good Health
555-555-
1000 Hospital
Ann Arbor
MI
Hospital
3004
Lane
GHH Inpatient Unit
555-555-
hospital
hospital unit (e.g., BMT)
3005 (ext
123)
hospital ward
GHH Patient Ward
555-5553006 (ext
456)
hospital room
GHH Room 234
555-5553007 (ext
789)
emergency room
GHH ER
555-5553008 (ext
246)
HL7 Version 3 Diet Orders 44
Role
Name
Phone
operating room
GHH OR
555-555-
Address
City
State
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
3009 (ext
321)
radiology dept.
GHH Radiology
555-5553010 (ext
654)
laboratory, in-house
GHH Lab
555-5553011 (ext
987)
pharmacy dept.
GHH Pharmacy
555-5553012 (ext
642)
outpatient clinic
GHH Outpatient
555-555-
Clinic
3013 (ext
999)
urgent care center
physical therapy clinic
home health care clinic
chiropractic clinic
optician clinic
pharmacy, retail
laboratory, commercial
nursing or custodial care facility
Community Urgent
555-555-
1001 Village
Care
4001
Avenue
Early Recovery Clinic
555-555-
1010 Village
4006
Avenue
Home Health Care
555-555-
1030 Village
Clinic
4008
Avenue
Bender Clinic
555-555-
1040 Village
4009
Avenue
See Straight
555-555-
1050 Village
Opticians
4010
Avenue
Good Neighbor
555-555-
2222 Village
Pharmacy
4002
Avenue
Reliable Labs, Inc.
555-555-
3434 Industrial
4003
Loop
Green Acres
555-555-
4444
Retirement Home
4004
Nursinghome
Drive
residential treatment facility
Home Away From
555-555-
5555
HL7 Version 3 Diet Orders 45
Role
Name
Phone
Address
Home
4005
Residential
City
State
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Ann Arbor
MI
Lane
satelite clinic
satelite clinic
satelite clinic
satelite clinic
Lone Tree Island
555-555-
1001 Lone Tree
Satellite Clinic
5001
Rd
Stone Mountain
555-555-
1000 Mountain
Satellite Clinic
5002
Way
Three Rivers
555-555-
1000 River
Satellite Clinic
5003
Drive
Bayview Satellite
555-555-
1000 Lakeside
Clinic
5004
Drive