For those who want to know the royal decree of the minimum set of data from clinical reports of the national health system ....
is a first step that has occurred in 2010, but the content that appears
199x Royal Decree 1093/2010, September 3, BY ADOPTING THE MINIMUM DATA SET FOR CLINICAL REPORTS ON NATIONAL HEALTH SYSTEM (BOE 16)
Law 41/2002 of November 14, regulating the patient's autonomy and rights and obligations regarding information and clinical documentation in Article 15 regulates the minimum content of each patient's medical history. The autonomous communities, in exercising its responsibility for management of health care, have been implementing different models and solutions for medical records or health history for the internal use of their facilities and services in recent years has replaced the traditional support role for digital or electronic. The degree of actual implementation of electronic medical records and service centers of the National Health System is now close to all of them in the level of care in primary health care, be expected that within a short time is reached similar level of implementation in specialized care centers and emergency medical.
In the third additional provision of the Act provides that the Ministry of Health in coordination and collaboration with relevant autonomous communities in the area, promote, with the participation of all stakeholders, implementing a support system that, given the evolution and availability of technical resources and the diversity of systems and types of medical records, enable use by healthcare institutions in Spain to attend the same patient, avoidance of those treated at several centers to undergo unnecessary examinations and repeat procedures.
Also, Article 56 of Law 16/2003 of May 28, cohesion and quality of the NHS, to instruct the Ministry of Health, with the agreement of the autonomous communities, coordinating mechanisms for electronic exchange of clinical information and to allow individual health professionals and stakeholders access to medical records.
Moreover, Law 11/2007 of 22 June, citizens' electronic access to public services and its implementing rules, deal with those aspects in which it is required that the regulatory provisions are common, such as interoperability, which, as the capacity of information systems and procedures that support the data sharing and enable the exchange of information and knowledge between them, is necessary for cooperation, development, integration and joint services by public administrations.
technological solutions exist that enable interoperability, defined as the transmission of data between heterogeneous information systems, of which one of them is the semantic interoperability. One of the steps necessary to achieve it is defined, by convention, the data set because of its relevance, must be contained in the various clinical reports describing the processes of health care made to individual citizens service center or the National Health. This homogeneity is one of the standards that facilitate the exchange between different systems in the service of citizens.
addition to the contribution which involves the standardization of the content of face to enable interoperability between different information systems, the introduction of basic models, demonstrated by experts as a tool to collect and present clinical information in a standardized way, it ensures consistency in content clinical documents in the public health system that facilitates their understanding and faster location of information, both patients and healthcare professionals, irrespective of the territory where they must be treated or where information is generated, giving thus fulfilling the mandate of the Law on Cohesion and Quality of National Health System.
This royal decree, addressed the diversity of systems and types of medical records existing in the area of \u200b\u200beach region, and the consensus of health professionals from different areas of knowledge, aims to provide the minimum data set should contain a series of clinical documents to reconcile and to enable use by all centers and assistive devices that make up the NHS. It also ensures the implementation of the provisions of this Royal Decree on the centers and assistive devices that serve the mutual and MUFACE beneficiaries, and MUGEJU ISFAS.
In developing this real decreto han sido oídos los colectivos profesionales implicados en la atención sanitaria, a través de un amplio conjunto de sociedades científicas de diferentes especialidades médicas y de enfermería. Asimismo han sido consultadas las comunidades autónomas, a través de grupos de expertos designados por la Subcomisión de Sistemas de Información, las Mutualidades de funcionarios civiles del Estado, de las Fuerzas Armadas y del personal al servicio de la Administración de Justicia; se ha sometido al pleno del Consejo Interterritorial del Sistema Nacional de Salud y cuenta además con el informe favorable de la Agencia Española de Protección de Datos.
Esta norma que tiene la condición de básica, in the sense referred to in Article 149.1.1. nd and 16. First of the Constitution, which places the responsibility for establishing the basic conditions guaranteeing equality of all English citizens in the exercise of their rights and in compliance constitutional duties and bases and general coordination of health, respectively, is issued in exercise of the authorizations granted by the third additional provision of Law 41/2002 of November 14 and Article 56 of Law 16/2003 of 28 May.
At its behest of the Minister of Health and Social Policy, with the prior approval of the First Deputy Prime Minister and Minister of the Presidency, as with the Council of State and after deliberation by the Council of Ministers at its meeting on September 3, 2010, decree: Article 1
. Purpose and Scope .- This royal decree is aimed at establishing the minimum data set should contain clinical documents listed in Article 3, whatever the medium, electronic or paper, in that they are generated.
The provisions of this Royal Decree shall apply to all facilities and assistive devices that make up the NHS.
Article 2. Structure data .- The clinical document content models in the annexes are comprised of different variables that are defined by the following properties:
1. Title or name of the variable.
2. Format (text, date, number ...).
3. Values. It refers to the different content that may be in the variable. For certain variables, the possible value should be included among those covered by a closed list.
4. Clarification. This is a brief discussion aimed at better understanding the allocation of value to the variable and its subsequent interpretation.
5. Character (set minimum or recommended.) The variable is the status of "minimum set" (CM) when their presence is required in any report format defined by any health service. This does not mean that the field to collect the values \u200b\u200bof this variable can not be void of data in some cases. Character is "recommended" (R) when their presence or absence in the reports is at the discretion of each region. When in a variable termed CM considered to have various sub-sections R, will not be required that the document is structured in such subsections but the content must match the areas described therein.
Article 3. Clinical documents .- 1. Clinical documents for establishing a minimum data set are:
a) the clinical discharge report, detailed in Annex I.
b) outpatient clinical report and detailed in Annex II.
c) emergency medical report, detailed in Annex III.
d) primary care clinical report and detailed in Annex IV.
e) Report of laboratory test results, detailed in Annex V.
f) Report of results of imaging tests, detailed in Annex VI.
g) Report on nursing care, detailed in Annex VII.
h) brief clinical history, detailed in Annex VIII. However
and within the scope of its powers the Autonomous Communities may establish their own models of clinical documents, incorporating such other variables as they deem appropriate, such models should include, in any case, all variables that comprise the minimum set of data, as listed in the Annexes to this real decree.
Includes Annex IX to collect a list of abbreviations used in the annexes to expression of full titles to which they correspond.
2. For the development of emergency medical report and the results of laboratory tests, different devices in emergency care in the first or the laboratories of the various specialties that generate results in the second, they must adopt different organizational structures of information as described in the relevant Annex.
3. The contents of the report of nursing care could be included in some of the clinical reports referred to in paragraph 2, in which case, will result in joint reports of doctor-nurse team. In this case, this report must comply with the minimum content established in each of the models that integrate data.
4. The summary of the history referred to in Article 3.1.h) is an electronic document, fed and automatically generated and updated at any time, from data that professionals will include in the patient's complete medical history. Additional provision
single additional provision. Clinical documents and beneficiaries mutual MUFACE, MUGEJU ISFAS and receive their health care under the concert concluded with free insurance .- 1. The provisions of this Royal Decree shall apply to facilities and assistive devices that the free insurance available to mutual members and beneficiaries of the Civil Servants' Mutual General of the State (MUFACE), the Social Institute of the Armed Forces (ISFAS ) and General Mutual Judicial (MUGEJU) under concerts they subscribe to and in terms of clinical documents thereof, in accordance with the provisions of Royal Decree 4 / 2000, dated June 23, 1 / 2000 of June 9 and 3 / 2000 of June 23 that those funds entrusted to the management of hedging mechanisms, including health, the Special Schemes of Social Security for Civil Servants, Armed Forces Staff and Service Administration of Justice, respectively.
2. In connection with the provisions of Articles 2.5 and 3.1 of this Royal Decree, the three Mutual, within its competence and in accordance with what is stated in the previous paragraph may include in their respective models of clinical documents other variables deemed appropriate. These models should include, in any case, all variables that comprise the minimum set of data, as listed in the Annexes to this royal decree. References to the "Health Service Name" in the "Data from the issuing institution" contained therein are deemed to be made to each of the three Mutual for the purpose of this additional provision.
3. The implementation of this additional provision regarding the interoperability of electronic health information systems that are the responsibility of the mutual funds in the National System Health, follows what is agreed for the entire national territory within the Inter-Territorial Council of the National Health System with the other authorities involved. TRANSITIONAL PROVISIONS
First transitional provision. Conservation of clinical documents .- clinical documents were generated before the entry into force of this Royal Decree may remain preserved in its current state.
second transitional provision. Adequacy of existing models .- Within 18 months after the entry into force of this Royal Decree will have adequate models of clinical documents it has been used new minimum contents therein. FINAL PROVISIONS
First final provision. Title .- This royal decree powers has the status of a basic rule in the sense referred to in Article 149.1.1. Nd and 16. First of the Constitution, which places the responsibility for establishing the basic conditions guaranteeing the equality of all the English in the exercise of rights and in fulfilling their constitutional duties and bases and general coordination of health, respectively.
Second final provision. Policy development .- It authorizes the head of the Ministry for Health and Social Policy, agreement of the Inter-Territorial Council of the National Health System, make the necessary arrangements for the implementation and development of the provisions of this Decree, and for the amendment of the annexes. Disposal
third. Entry into force .- The present Royal Decree shall enter into force on the day following its publication in the Official Gazette. " ANNEX I
DataSet clinical discharge report
Variable Values \u200b\u200bFormat Clarifications CM/R1
INFORMATION DOCUMENT Document Type Text High CM Clinical Report
Signing Date dd / mm / yyyy Common to both Commonwealth feet of signing the report CM
Join Date dd / mm / yyyy CM
Free Registration Date dd / mm / yyyy CM
Free 1 Free text Responsible Name (name + 2 names) is part of the first foot of signing the report CM Professional Category 1 Text
CM Resident Physician Area Medical Specialist
Section Chief Head of Service Responsible
2 Free Text Name (name + 2 names) is part of the second foot signature, often supervising the first author professional Category 2 Text
Medical Specialist CM Area Section Head
Head of Service
Text Under current regulations at all times. Currently: Service classification of MDS / SIFCO Free Text
CM CM Unit
DATA Name issuing institution
Health Service Logo Text +
SAS. Andalusian Health Service. HEALTH
CM. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
services
Text + Free R
Logo Center Heading Text + Logo
RECESS CNH and then when available + There will be a free text Additional free text field for those schools not included in the inventory force to be newly opened CM
Centre Division via text type RECESS CNH and then when it is available free text + CM
Name CM road
Text Number Text via Text Zip
CM CM CM
Province Municipality Text Text Text Country
CM CM CM
Phone Text Web address / Email Text Free web address will be included only if it contains information of interest to the user R
1 You can classify each country as their presence is deemed essential (though the completion of the value is not required) and should therefore be part of the minimum set of SNS (CM) or otherwise their presence is desirable but not essential as part of minimum data set (R).
Variable Values \u200b\u200bFormat Clarifications CM/R1
PATIENT INFORMATION Name Text Data contained in the database of the TSI of the CA CM CM
First Name Last Name Text Text
CM Date of birth dd / mm / yyyy Text Sex
CM H / M CM
DNI / T. Residence / Passport Text Text NASS R
CM CIP
C. CM
Autonomous Text Text Code R SNS Text
European CIP this space is reserved in anticipation that in future, there is a European code / international ID No. R
Free Text Medical Record Home
CM
via Text Type Data contained in the database of the TSI of the CA CM
Name
CM via Text via Text Number CM CM
Floor
Send Text Text Text Zip
CM CM CM
Province Municipality Text Text Text Country CM
Text Phone Data contained in the TSI BD AC + There will be free text free text to add a second A phone number
CARE DATA PROCESSING Reason
High Text Home Moving categories are included for the national minimum data set, regardless of whether the MDS autonomous actually incorporate additional categories, the answers are then recycled. The death response category will be recoded to 'death: "CM
Service Transfer Transfer to another hospital
Transfer to a voluntary health center
High
Death
Other Reason for admission
Free Text + ICD-9 CM Code / CIE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council CM Interterritorial
Type R
Timed Text entry Urgent CM CM
Background Free Text
familial hereditary diseases
Free Text 1) childhood immunizations, adult, chemoprophylaxis made, etc. Previous illnesses
R (2) Refers to assessing the functional impact of active problems or diseases and may use one or more scales (Scales of dependence, functional classification of heart failure, assessments of the degree of dementia, quality of life scales, etc.).
Neonatal history, obstetric and surgical
Allergy precautionary actions
toxic habits (1)
Premedication functional status (2) social and professional background
Current History Free Text
Physical Exploration CM CM
Free Text Free Text Summary CM additional evidence Laboratory
Free Text classification is recommended in subsections R
Image
Other tests and reviews developments
Text Free In your case, you surgical protocol included in this section, as well as comments to the diagnosis or treatment, additional diagnostic assessments, describe whether the involuntary psychiatric admission was to describe adverse reactions to drugs or other substances used in this episode, the evolutionary complications / diseases or do diagnostic assessments or additional comments. CM Principal Diagnosis
Text + code +
Free ICD-9 CM Code / CIE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council Interterritorial. CM
R
Other Diagnostics Text + code
+ Free ICD-9 CM Code / CIE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council Interterritorial. CM
R
Procedures
Text + code +
Free ICD-9 CM Code / CIE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council Interterritorial. CM
R
CM
Treatment Recommendations Free Text Free Text These recommendations do not include drug therapy (oxygen, diet, rest or physical effort limitations, etc.).
Drugs R
Text + Free
code (principioactivo + Specialty + dose / unit + No units / dose + dose range management + life + path)
gazetteer MSPS official (country code) / Snomed-CT
the extent that the implementation of EHR applications, including modules of limitations, permit, free text will be replaced gradually by the vocabulary of the catalog approved drug (List Officer / Snomed-CT) R
Other Recommendations Free text refers to the action plans provided that proper measures are not therapeutic. For example, date of next appointment, convenience of further review, requests for tests, etc. CM
1 You can classify each country as their presence is deemed essential (though the completion of the value is not required) and should therefore be part of the minimum set of SNS (CM) or else its presence is desirable but not necessary as part of minimum data set (R). ANNEX II
Data Set outpatient clinical report
Variable Values \u200b\u200bFormat Clarifications CM/R2
INFORMATION DOCUMENT Document Type Text Outpatient Clinical Report CM
Signing Date dd / mm / aaaa Free Common to both feet in signing the report CM
Consultation Date dd / mm / yyyy CM
Free 1 Free text Responsible Name (name + 2 surnames) CM
Professional Category 1 Text Medical Resident Medical Specialist
CM area is part of the first foot of signing the report
Section Chief
Name Head of Service Manager 2 Free text (name + 2 names) is part of the second foot signature, usually oversee the first CM signatory
Professional Category 2 Text Area Medical Specialist Section Chief
CM
Head of Service
Text According to regulations in force at the present time: Service classification of MDS / SIFCO
CM CM Unit Free Text
DATA Name issuing institution
Health Service Logo Text +
SAS. Andalusian Health Service. HEALTH
CM. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
services
Text + Free R
Logo Center Heading Text + Logo
RECESS CNH and then when available + There will be a free text Additional free text field for those schools not included in the inventory force to be newly opened CM
Centre Division via text type RECESS CNH and then when Free text available + There will be an additional free text field for those sites not listed on the inventory be enforced by newly opened CM
Name Text via CM
Number Text via Text Zip
CM CM CM
Text Municipality
Province Country Text Text
CM CM CM
Phone Text Web address / Email Text Free web address will be included only if it contains information of interest to the user R
PATIENT INFORMATION Name Text Data contained in the BD CM AC IST
First Name Last Name Text Text
CM CM
Birthday dd / mm / yyyy
CM Text Sex M / M CM
DNI / T. Residence / Passport Text Text NASS R
CM CIP
C. CM
Autonomous Text Text Code R SNS Text
European CIP this space is reserved in anticipation that in future, there is a European code / international ID No. R
Free Text Medical Record Home
CM
via Text Type Data contained in the BD AC IST CM
Name
CM via Text via Text Number
Floor CM CM
Send Text Text Text Zip
CM CM CM
Province Municipality Text Text Text Country CM
Text Phone
Data contained in the database of the TSI CA + There will be free text free text to add a second telephone number R
CARE DATA PROCESSING Reason for Consultation
Text + code +
Free ICD-9 CM Code / IE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council Interterritorial CM R
Background Free Text classification is recommended in subsections CM
familial hereditary diseases (1) childhood immunizations, adult, chemoprophylaxis made, etc.
(2) It refers to the assessment of the functional impact of active problems or diseases and may be used one or more scales (Scales of dependence, functional classification of heart failure, Ratings of degree of dementia, quality of life scales, etc.).
R
previous Diseases Neonatal history, obstetric and surgical
Allergies Toxic habits
Actions Preventive (1) Premedication
functional status (2) social and professional background
CM Contemporary History Free Text Free Text
Physical Exploration Summary
CM additional tests
CM Laboratory Free Text Free Text classification is recommended in subsections R
Image Other tests
Evolution and comments can be made free text comments evolutionary track in the event that the report does not refer to a single query but a follow-up period in which there have been several clinical interviews. In this case we can include here the period of time that is comprehensive review report or the dates when the consultations took place. It is also the place to describe adverse reactions to drugs used in this episode or describe the evolutionary complications / diseases, perform diagnostic evaluations or comments
CM Principal Diagnosis Code Text +
+ Free ICD-9 CM Code / CIE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council Interterritorial
R
CM Other Diagnosis
Text + code +
Free ICD-9 CM Code / CIE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council Interterritorial
CM Procedures
R
Text + code +
Free ICD-9 CM Code / CIE 10/SNOMED-CT
systems coding will be replaced later if agreed at the Inter-Territorial Council CM NHS R
CM
Treatment Recommendations Free Text Free Text These recommendations do not include drug treatment (oxygen therapy, diet, rest or physical effort limitations, etc.).
Drugs R
Text + code
Free (active + Specialty + dose / unit + No units / dose + dose range management + life + path) Official List MSPS (country code) / Snomed-CT active prescriptions at the end of follow-up period the extent that the implementation of EHR applications, including prescribing modules, permitting, free text will be replaced gradually by the vocabulary of the catalog of approved drugs (Official List / Snomed-CT) R
Other Recommendations Free text refers to the action plans that are not properly planned therapeutic measures. For example: date of next appointment, convenience of further review, requests for tests etc. CM
2 You can classify each country as their presence is deemed essential (though the completion of the value is not required) and should therefore be part of the minimum set of SNS (CM) or else its presence is desirable but not necessary as part of minimum data set (R).
ANNEX III
DataSet emergency clinical report
Variable Format Reference Values \u200b\u200bClarification
CM/R3
INFORMATION DOCUMENT Document Type Clinical Report Emergency Text
CM Signing Date dd / mm / yyyy Common to both Commonwealth feet of signing the report R
Date and time of entry or activation of the resource dd / mm / yyyy hh: mm CM
Free Time High dd / mm / yyyy hh: mm CM
Free 1 Free text Responsible Name ( surname name + 2) CM
Professional Category 1 Text
FacultativoJefe Resident Physician Section Head of Service
is part of the first foot of signing the report CM
Name Head 2 Freedom (name + 2 surnames) CM
Category 2 Optional
responsible Section Chief Head of Service
walk is part of the second signature, often supervising the first author CM Care Unit responsible
Text Emergency Service CM Hospital Emergency Service
A. Primary
Emergency SAMU
S. ·
DATA + free text of the issuing institution
Health Service Name SAS Text. Andalusian Health Service. CM Logo
+ HEALTH. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Health Service
Murciano-O SNS. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
services
Text + R logo
Title Free Text Center
CNH
+ logo to Specialty Care Centers
Centers Primary Inventory
RECESS for both when it is available free text
+ There will be an additional free text field for those sites not listed on the inventory in place to be CM
newly opened Centre Division
CM type
via Text via Text Name
CM
Number Text via Text Zip
CM CM CM
Province Municipality Text Text Text Country
CM CM CM
Phone Text
Web Address / E-mail the web address will be included only if it contains information of interest to the user R
PATIENT INFORMATION Name Text Data contained in the TSI BD AC
CM CM
First Name Last Name Text Text
CM Date of birth dd / mm / yyyy H CM
Text Sex / M CM
DNI / T. Residence / Passport Text Text NASS R
CM CIP
C. CM
Autonomous Text Text SNS Code CIP R European
this space is reserved in anticipation of future under a European code / international ID No. R
Free Text Medical Record
R
Address Data Type via text contained TSI in BD AC Variable Format
CM Benchmarks Clarifications CM/R3
Name
CM via Text via Text Number
Floor CM CM
Send Text Text Text Zip
CM CM CM
Text
City Province Country
CM Text Text Text Telephone
R
Text Reference Person free (name + 2 surnames) R
Reference Phone Free Text
R
CARE DATA PROCESSING Text Hometown Family Physician / Pediatrician AP R
By decision of the patient or family
Other Security Forces Emergency Services
Type Text refers Disease R
traffic accident Work Accident Other Accident
Reason High Income Text Categories include those for the national minimum data set, regardless of whether the MDS autonomic responses incorporate additional categories which are then recycled. The category of response to death: death will be recoded CM
Transfer Transfer Delivery Service
Transfer to another hospital
Transfer to a voluntary health center
High
Death
Other Reason for Consultation
Text + Free
code
+ ICD-9 CM Code / CIE 10/SNOMED-CT
coding systems will be replaced later if agreed at the Council Interterritorial. CM
Background
R
CM
Disease Free Text Free Text Prior (1) Refers to the assessment of the functional impact of active problems or diseases, and may use one or more scales (Scales of dependence, functional classification of heart failure , reviews the degree of dementia, quality of life scales, etc.).
R Neonatal history, obstetric and surgical
Allergy Premedication
functional status (1) social and professional background
Current History Free Text
Physical CM CM
TA (/) FC () beats / min Text
Free R FR () resp / min
Temp. () ° C
O2 saturation capillary blood glucose
exploration roundup Summary of additional tests
Free Text classification is recommended in subsections CM Laboratory
R
Free Text Image
Other tests
Evolution and Free text comments can be included where appropriate, well as progress notes and the period of observation, description of techniques performed during the care process. It is also the place to describe adverse reactions to drugs used in this episode, the evolutionary complications / diseases, perform diagnostic evaluations or comments
CM Diagnosis Text
main
+ Free
code ICD 9 CM Code / CIE defined 10/CIAP2 /
SNOMED-CT coding systems will be replaced later if agreed at the Council Interterritorial CM
R
Other diagnoses
Text + Free
code ICD 9 CM Code / CIE defined 10/CIAP2 /
SNOMED-CT coding systems will be replaced later if agreed at the Council Interterritorial
R
CM Procedures
Text + Free
code ICD 9 CM Code / CIE 10/CIAP2 defined /
SNOMED-CT coding systems will be replaced later if agreed at the Council Interterritorial CM
R
CM
Treatment Recommendations Free Text Free Text These recommendations do not include drug treatment (oxygen therapy , diet, rest or physical effort limitations, etc.).
Drugs R
Text + Free
code (Specialty + active + dose / unit + No units / dose + dose range management + life + path)
Official List
MSPS (country code) / Snomed-CT
active requirements.
To the extent that the implementation of EHR applications, including modules limitation, permit, free text will be replaced gradually by the vocabulary of the catalog of approved drugs (Official List / Snomed-CT)
R
Other Free text recommendations refers to the action plans that are not properly planned therapeutic measures. For example: date of next appointment, convenience of further review, requests for tests, etc. CM
3 You can classify each country as their presence is deemed essential (though the completion of the value is not required) and therefore should be part of minimum set of SNS (CM) or else its presence is desirable but not essential as part of minimum data set (R). ANNEX IV
data set of primary care clinical report
Variable Values \u200b\u200bFormat Clarifications CM/R4 INFORMATION DOCUMENT
Text Document Type Primary Care Clinic Report CM
Signing Date dd / mm / aaaa Free Date which issued the report. Common to both feet
CM signing period start date dd / mm / aaaa Free Date the beginning of the period of monitoring in registering the various episodes and actions described CM
period end date dd / mm / Free yyyy Date on which follow-up period ends in registering the various episodes and actions CM
sedescriben Responsible Name 1 Free text (name + 2 names) is part of the first foot of signing the report CM
Medical Professional category 1 Text
Resident Family Doctor Pediatrician AP
Free Text Free Text Name Responsible 2 (name + 2 surnames) CM
Category 2 Text responsible family doctor is part of the second foot signature, often overseeing the first signatory
Pediatrician AP CM
Free Text
DATA Name issuing institution
Health Service SAS Text + logo. Andalusian Health Service. CM
HEALTH. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
services
Text + R logo
Title Free Text Center
+ logo Inventory Primary Care Center and later RECESS when available + There will be a free text Additional free text field for those sites not listed on the inventory be enforced by newly opened CM
Centre Management Type Inventory Text via primary care centers and later RECESS text when available + free CM
Name
CM via Text via Text Number Text
Floor CM CM CM
Send Text Postal Code Township Text Text
CM CM CM
Province Country Text Text Text Telephone
CM CM
Web address / Email Text Free web address will be included only if it contains information of interest to the user R
DATA USER / PATIENT
Name Text Data contained in the TSI BD AC
CM CM
First Name Last Name Text Text
CM Date of birth dd / mm / yyyy Text Sex
CM H / M CM
DNI / T.Residencia / Passport Text Text NASS R
CM CIP
C. CM
Autonomous Text Text SNS Code CIP R European
this space is reserved in anticipation of the future there is a European code / international ID No. R
Free Text Medical Records Data Address
CM contained in the BD AC IST
via Text Type CM
Name
CM via Text via Text Number CM CM
Floor
Send Text Text Text Zip
CM CM CM
Province Municipality Text Text Text Country CM
R
Phone Text Reference Person Free text (name + 2 surnames) This is the person representing the interests Patient R
Free Text Reference Phone HEALTH DATA R
Background Free Text classification is recommended in subsections CM
familial hereditary diseases (1) childhood immunizations, adult, chemoprophylaxis made, etc.
(2) Refers to the assessment of the functional impact of active problems or diseases and may use one or more scales (Scales of dependence, functional classification of heart failure, assessment of the degree of dementia, quality of life scales , etc.) Previous illnesses
Neonatal history, obstetric and surgical
Allergy precautionary actions
toxic habits (1) Premedication
functional status (2) social and professional background
Summary Free Text CM additional evidence
Image Lab
Other tests
Free Text classification is recommended in subsections R
Served Episode Summary Text + Free
code ICD 9 CM Code / CIE defined 10/CIAP2 / SNOMED
-CT coding systems will be replaced later if agreed at the Council Interterritorial CM R
Evolution and comments can be made free text comments evolutionary track. It is also the place to describe adverse reactions to drugs used or describe the evolutionary complications / diseases, conduct reviews CM diagnostic or comments
Diagnostics
Text + Free
code ICD 9 CM Code / CIE defined 10/CIAP2 /
SNOMED-CT coding systems will be replaced later if agreed at the Council Interterritorial CM R
Procedures
Text + Free
code ICD 9 CM Code / CIE defined 10/CIAP2 /
SNOMED-CT coding systems will be replaced later if agreed at the Council Interterritorial
CM R Free Text
treatment refers to the latter treatment is active CM
Recommended Text It's free treatment recommendations that do not include drugs (oxygen therapy, diet, rest or physical effort limitations, etc.).
Drugs R
Text + Free
code (Specialty + active + dose / unit + No units / dose + + via the dosing interval administration + duration) Official List
MSPS (country code) / Snomed-CT
active prescriptions at the end of follow-up period
the extent that the implementation of EHR applications, including prescribing modules, permit, free text will be replaced gradually by the vocabulary catalog of approved drugs (Official List / Snomed-CT)
CM R
Other Recommendations Free text refers to the action plans that are not properly planned therapeutic measures. For example: date of next appointment, convenience of a review, requests for tests, etc. R
4 You can classify each country as their presence is deemed essential (though the completion of the value is not required) and should therefore be part of the minimum set of SNS (CM) or else its presence is desirable but not necessary as part of minimum data set (R). ANNEX V
dataset of the results report laboratory tests
Variable Values \u200b\u200bFormat Clarifications CM/R5
INFORMATION DOCUMENT Document Type Text Report of Laboratory Test Results
CM Signing Date dd / mm / aaaa Free Common to both feet on signing the report CM Responsible Name
1 Free text (name + 2 names) is part of the first foot of signing the report CM
Professional Category 1 Text Optional
Resident Physician Specialist Pharmacist
Area Resident Resident Biologist
Section Chief Head of Free Text
CM Manager 2 Free Text Name (name + 2 names) It is part of the second foot signature, often supervising the first author CM
Professional Category 2 Text Area Medical Specialist Section Chief
Head of CM
Free Text Service Text Analysis
Clinical Pathology
Hematology Clinical Biochemistry and Genetics
Hemotherapy
Immunology, Microbiology and parasitology
RD 1277/2003 and regulations in force at all times
CM CM Unit Free Text
STATION INFORMATION ABOUT THE INSTITUTION
Health Service Heading Text SAS. Servicio Andaluz Health. CM Logo
+ HEALTH. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Agencia Valenciana de Salut. Osakidetza
Basque Health Service. Name of vicar
services
Text + Free R
Logo Center Heading Text + Logo
RECESS CNH and then when available + There will be a Free text Additional free text field for those schools not included in the inventory force to be newly opened CM
Centre Division via text type RECESS CNH and then when it is available free text + CM
Name Text via CM
Number Text via Text Zip
CM CM CM
Text Municipality Text
CM
Country Province Text Phone Text
CM CM
Web address / Email Text Free web address will be included only if it contains information of interest to the user R
PATIENT INFORMATION Name Text Data contained in the database of the TSI
CM AC First Name Last Name Text Text
CM CM
Date of birth dd / mm / yyyy Text Sex
CM H / M CM
DNI / T. Residence / Passport Text Text NASS R
CM CIP
C. CM
Autonomous Text Text Code R SNS Text
European CIP this space is reserved in anticipation that in future, there is a European code / international ID No. R
Medical History Free Text
CM No. Bed / No Consultation Free Text
R
PERSONAL INFORMATION Name of Health Service Logo Text +
SAS. Andalusian Health Service. HEALTH
CM. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Health Service
Murciano-O SNS. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
services
Text + Free R
Logo Center Heading Text + Logo
RECESS7 CNH6 and then when available + There will be a free text Additional free text field for those schools not included in the inventory force to be newly opened CM
Text Service Under current regulations at all times present classification of the MDS Services / SIFCO Free Text
CM CM Unit
Applicant Name Free text (name + 2 surnames) CM Professional Category
Text
CM Resident Physician Area Medical Specialist Section Chief
Head of Family Doctor Pediatrician AP
Free Text
CARE DATA PROCESSING DATA SAMPLE
sampling date dd / mm / yyyy CM
Free Text Free Sample number Sample type CM
Text + Free Logo
CM Biochemistry: LOINC R
Haematology Immunology
LOINC: LOINC
Genetics, Microbiology
LOINC Vocabulary from LOINC local
A. Pathology: Snomed-CT determination
Text Group General Biochemistry General Biochemistry Systematic CM
urine • metabolites (eg glucose, urea, creatinine, etc.).
Hormones • Enzymes (AST, ALT, LDH, etc.).
• Tumor markers ions (Na, K, Cl, Ca, P, Mg, etc.).
and toxic drug levels
Gasometry
• Other proteins (cardiac markers, etc.).
Hematology • Biological Fluids Hemostasis (Coagulation)
Hemotherapy
• semen and semen studies
Hematology-Coagulation, Special Testing • Studies in feces
Immunology-Allergy • Trace elements (Cu, Se, etc.).
Microbiology • Proteins (transferrin, ceruloplasmin, complement, etc.).
Genetics • Protein electrophoresis
Pathology - Biopsies
Pathology - Cytology
• immunofixation / immunosubstration
• Immunoglobulins and light chains
Systematic
• Urinalysis Urine Sediment
• Hormones • Hormones
• Vitamins • Other related immunoassays (eg PAPPA)
• Tumor markers Serum tumor markers
• Molecular Pathology neoplastic hematologic diseases
• Molecular Pathology malignancies, solid tumors
and toxic drug levels
• Monitoring • Drug abuse Drug Detection
• Detection of other toxins (heavy metals, toxic workplace, etc. .)
• Pharmacogenomics
Gasometry
Hematology
• manual and automated blood count (including the CBC, the automated and manual differential count, erythrocyte morphology, ESR, plasma viscosity, etc.).
Hemostasis (coagulation)
• Evidence of basic Haemostasis (prothrombin time, activated partial thromboplastin time and fibrinogen)
Hemotherapy
• Immunohematology studies (detection of irregular antibodies)
•
transfusion compatibility tests Hematology Coagulation: Special tests
• Cytochemistry, Cytometry, Cytogenetics and Molecular Biology of peripheral blood and bone marrow (includes all diagnostic markers)
• Bone marrow aspiration and biopsy Bone marrow (includes all bone marrow studies)
• Anemia Studies
• Tests for study of hemorrhagic diathesis
• Tests for Thrombosis study
• Molecular Biology of congenital or acquired hemostasis
Immunology - Allergy
• Autoimmunity Immunochemistry
• • •
Histocompatibility
Microbiology Immunology Bacteriology
• • •
Virology Parasitology Mycology
• • •
Infectious Serology Infectious Molecular Biology Genetics
• • Pathology Cytogenetics / Molecular Genetics
Pathology - Biopsies
• Biopsies and surgical specimens
• Immunohistochemistry • Molecular Pathology
• electron microscopy • Flow cytometry
Pathology - Cytology
• FNA Cytology and Immunocytochemistry
• • Molecular Pathology
• Electron microscopy
•
flow colometry TYPE Model This model can list all the results of diagnostic tests that are expressed with a name determination, a result (usually expressed in figures), the units of measurement used and a range of reference values \u200b\u200bare taken as standard normal. Determination
eg blood biochemistry CM
Result Free Text Free Text Free Text Units
CM CM CM
Range Free Text Free Text Comments TYPE R
Model B This model can list all the results of diagnostic tests that require a description and a conclusion free text. Eg bone marrow study Determination
Text Text Free Technical
CM CM CM
Free Text Description Text +
Conclusion
Code Free
SNOMED
CM
R
5 You can classify each country as their presence is deemed essential (though the completion of the value is not required) and should therefore be part of the minimum set of SNS (CM) or else, their presence is desirable but not essential as part of minimum data set (R). CNH
6: National Catalogue of Hospitals.
7 RECESS: General Register of Establishments, Health Services Centres and MSPS. ANNEX VI
report data set of test results
Image Format Variable Values \u200b\u200bClarification CM/R8
INFORMATION DOCUMENT Document Type Text Performance Report CM imaging
Signing Date dd / mm / aaaa Free Common to both feet in signing the report CM
Responsible Name 1 Free text (name + 2 names) is part of the first foot
signing the report CM Professional Category 1 Text
CM Resident Physician Area Medical Specialist Section Chief
Head of Service Responsible
2 Free Text Name (name + 2 names) is part of the second foot signature, usually oversee the first CM signatory
Professional Category 2 Text Area Medical Specialist Section Chief
Head of Service
Text
Medicine Radiology CM Unit
Nuclear Free Text
CM DATA Name issuing institution
Health Service Logo Text +
SAS. Andalusian Health Service. HEALTH
CM. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
services
Text + Free R
Logo Center Heading Text + Logo
RECESS CNH and then when available + There will be a free text Additional free text field for those schools not included in the inventory force to be newly opened CM
Center Address Type CM
via Text via Text Name
CM Street number Zip
CM Text Text RECESS CNH and then when available + Free Text Text Municipality
CM CM CM
Province Country Text Text Text Telephone
CM CM
Web address / Email Text Free web address will be included only if it contains information of interest to the user R
PATIENT INFORMATION Name Text Data contained in the database of the TSI of the CA CM CM
First Name Last Name Text Text
CM Date of birth dd / mm / yyyy Text Sex
CM H / M CM
DNI / T. Residence / Passport Text Text NASS R
CM CIP
C. CM
Autonomous Text Text Code R
SNS European CIP Text this space is reserved in anticipation that in future, there is a European code / international ID No. R
Free Text Medical Record No. CM
Bed / Free Text Query No. R
DATA Applicant Name
Health Service Logo Text +
SAS. Andalusian Health Service. HEALTH
CM. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Management of Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
services
Text + Free R
Logo Center Heading Text + Logo
RECESS10 CNH9 and later) when available + There will be a free text Additional free text field for those centers not listed in the inventory be enforced by newly opened CM
According Text Service regulations in force at all times present classification of the MDS Services / SIFCO
CM CM Unit
Free Text Free Text Name of applicant (name + 2 surnames) CM Professional Category
Text
CM Resident Physician Area Medical Specialist Section Chief
Head of Family Doctor Pediatrician
AP
Optional Free Text
CARE DATA PROCESSING
Free Text Clinical Data will reflect the same content as the driving Request
CM exploration is the place to detail the clinical data which justify the conduct of the test and establish the diagnostic suspicion
CM Exploration
Text + Free Code (Numeric string + string) SERAM into force
Catalog Catalog
SEMN into force
Exploration R
Date dd / mm / aaaa Free CM
Description Free text scan is a detailed description of the exploration carried out, which may also be realized: R
• Priority (normal, urgent)
• contrast media (type, dose and injection rate
• Adverse Reactions
• Other events (lack of cooperation, anxiety, claustrophobia ...) and management of these technical limitations
• • Exploration with which we compare and date thereof Findings
Free text is a detailed description of the findings, which may also be realized: CM
• negative findings
• Comparison Previous studies
• Limited diagnostic
CM Diagnosis
Text + Free Chain Code text (catalog name used) + R
Recommended Code assigned text book is the place to pick up: CM
care or treatment to be followed after completion scan diagnostic or interventional
Indication other examinations to be performed to complete the study of the patient or the period within which to perform a scan control
8 each field can be classified according to their presence is deemed essential (although not filling in the value is mandatory) and therefore should be part of the minimum set of SNS (CM) or else its presence is desirable but not essential as part of minimum data set (R). CNH
9: National Catalogue of Hospitals.
10 RECESS: General Register of Establishments, Health Services Centres and MSPS. ANNEX VII
report data set for nursing care
Variable Format Values \u200b\u200bClarification
CM / R 11
INFORMATION DOCUMENT Document Type Text
Nursing Care Report CM
Signing Date dd / mm / aaaa Free Common to both feet on signing the report CM
Date dd Nursing Assessment / mm / yyyy Date Added
Free CM / Nursing Referral Date dd / mm / aaaa Free
CM
Nurse Nurse Manager 1 Free text (name + 2 names) is part of the first foot of signing the report CM
Nurse Professional Category Head Nurse 1 Text
CM Resident Nurse Nurse Practitioner
(EIR)
Nurse Manager 2 Free text (name + 2 names) is part of the second foot signature, often supervising the first author CM
Category 2 Text Vocational Nurse Nurse Manager Nurse Practitioner CM
Text
Device Center Health Care CM
Hospital Emergency Hospital Hospital Emergencies
Other Healthcare Centre
STATION INFORMATION ABOUT THE INSTITUTION
Health Service Name SAS Text. Andalusian Health Service. CM Logo
+ HEALTH. Aragon Health Service.
SESPA. Health Service of the Principality of Asturias.
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha.
SACYL. Regional Health Management Castile Lion.
DoS-GC. Departament de Salut de la Generalitat de Catalunya
SES. Extremadura Health Service.
SERGAS. Servizos Galego de Saúde.
INGESA. National Institute of Health Management. IB-SALUT
. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
Services Free Logo Text + R
designation Text + Logo CNH12 Center for Specialty Care Centers, Department of Primary Inventory and then RECESS13 when Free text is available + There will be an additional free text field for those sites not listed on the inventory into force because of their recent opening of the Center Address
CM
via Text Type RECESS CNH and then when it is available free text + CM
Name CM road
Text Number Text via Text Zip
CM CM CM
Province Municipality Text Text Text Country
CM CM CM
Phone Text Web address / Email Text Free web address will be included only if it contains information of interest to the user R
PATIENT INFORMATION Name Text Data contained in the BD AC IST
CM CM
First Name Last Name Text Text
CM Birthday dd / mm / yyyy Text Sex
CM H / M CM
DNI / T. Residence / Passport Text Text NASS R
CM CIP
C. CM
Autonomous Text Text Code R SNS Text
European CIP this space is reserved in anticipation that in future, there is a European code / international identification. R
Medical Record No. CM
Free Text
Address Data Type via text contained in the database of the TSI of the CA CM
Name
CM via Text via Text Number Text CM CM
Floor Lyrics Zip
CM Text Text Text Municipality
CM CM CM
Province Phone Text Text Data contained in the TSI BD AC + There will be free text free text to add a second telephone number R
Reference Person Free text (name + 2 names) This is the person representing the interests of patient CM
Reference Phone Free Text
CM CARE DATA PROCESSING
causes of the Free Text Nursing interventions Motive High CM
/ Referral Nurse CM
Text Transfer Income
Moving home
Service Transfer to hospital
Transfer to a voluntary health center
High
Other
Death Background and environment
Free text highlight only the information relevant previous illnesses CM
Free Text (1) Vaccinations and state
(2) The set of factors outlined refers to those elements (personal, family, social or professional) that part of your environment can affect or influence the evolution of his health. They also accommodate those specific events (loss of family labor event, ...) that may influence their response to different health situations
R
Surgical
Allergy Drug Treatments
precautionary actions (1)
personal factors, family, social, cultural and employment highlights (2). Nursing Diagnosis resolved
Text +
Literal code
NANDA NANDA
+ Code is to highlight those diagnoses, and questions which may be of interest to predict subsequent appearances CM R
care protocols in which is included free text have accommodate all care processes and health programs in which you are included, both preventive and monitoring programs, rehabilitation and health education among others. And interdependent relationship problems and / or collaboration if any active rating
CM Text Free Reference Model CM
used
Free Text
Notable results should reflect the information on the latest nursing assessment
CM CM recommend specifying other scales or tests used and outside the model used in the general valuation assets Nursing Diagnoses
Text +
Literal code + Code
NANDA NANDA diagnoses
Those present at the time of the report, both actual and potential CM R
Nursing Outcomes
Text + NOC code Literal
+
Those NOC Code selected results to identify patient outcomes as a result of planned interventions CM R
Nursing Interventions Text +
Literal code
NIC + NIC
interventions being carried out at the time of preparing the report CM R
Caregiver Home Free text (name, surname + 2) + Link to the user should indicate both the name and the relationship he has with him (family, caregiver outside ...) CM
R
Additional information / comments Free text can include information on the presence of catheters, prostheses, special diets, and to highlight some aspect of special significance on the application of active interventions
11 R
each field can be classified according to their presence is deemed essential (though the completion of the value is not required) and should therefore be part of the minimum set of SNS (CM) or else its presence is desirable but not essential as part of minimum data set (R). CNH
12: National Catalogue of Hospitals.
13 RECESS: General Register of Establishments, Health Services Centres and MSPS. ANNEX VIII
DataSet medical history summary
CM/R14 Variable Format Values \u200b\u200bClarification Data Dump 15
INFORMATION DOCUMENT Acceso16
Text Document type AP Medical History Summary CM / C
Creation Date dd / mm / yyyy AP Free CM / C
Last updated dd / mm / yyyy Libre date which was modified any of the components of the record was last AP CM / C DATA
issuing institution Name of Health Served SAS Text + logo. Andalusian Health Service. AP CM / C
HEALTH. Aragon Health Service.
SESPA. Health Service of Asturias
Canary Islands Health Service.
SCS. Cantabria Health Service.
SESCAM. Health Service of Castilla-La Mancha
SACYL. Regional Management Health of Castilla y León.
DoS-GC. Departament de Salut de la Generalitat de Catalunya.
SES. Extremadura Health Service.
SERGAS. Servizos
INGESA Galego de Saúde. National Institute of Health Management
IB-SALUT. Health Service Illes Balears.
RIOJASALUD. Riojano Health Service.
Madrid Health Service. Murciano
Health Service. SNS-O
. Navarra Health Service-Osasunbidea.
Valencia Region of Health. Osakidetza
Basque Health Service. Name of vicar
service Free Text + R logo
USER DATA / PATIENT
Name Text AP CM / C
AP CM Text First Name / Last Name text C
AP CM / C
Date of birth dd / mm / yyyy Data contained in the IST BD AP CM / C
Text Sex M / F CM AP / C
DNI / T.Residencia / Passport Text RAP / C
Text NASS AP CM / CIP
C. C Text autonomous AP CM / C
SNS Code Text RAP / C
European CIP this space is reserved in anticipation of that future, there is a European code / identification international RAP / C No.
Free Text Medical Records CM AP / C
via Text Data Type that appears on the BD AC IST AP CM / C
Name Text via AP CM / C
Number Text via AP CM / C Flat Text
AP CM / C
Lyrics AP CM Text / C
Code AP CM Postal Text / C
Text Municipality AP CM / C
AP CM Text Province / C
Phone Text RAP / C Reference person
Free text (name + 2 names) This is the person representing the interests of the RA patient / MP / C reference
Phone Free Text RA / MP / C Primary Caregiver
Free text (name + 2 surnames) RA / MP / C
HEALTH DATA Information is reserved for patient decision Button s / n YES
NO
This field informs the seller that there is some clinical data that is not in the HC by decision of the CM patient AP / C
advance directive exists Button s / n YES NO
professional Informs that there is this document which is available at the Registry of Last Wills CM A / MP / C
is included in clinical research protocol Button s / n YES NO
Reports inclusion in a research protocol at the time of last update RMP / C
AP CM Allergy Free Text / C
AP CM Vaccinations Free Text / C
Solved, Closed or Inactive + Free Text Text Date Specify the date of closing and the reason RAP / C Problems and active episodes
Text + Text +
date books that appear in history at the time of last update CM
R
AP / C
Code ICD-9 Coding System
MC / CIE 10/CIAP 2
Defined /
SNOMED-CT coding systems will be replaced later if agreed at the Council of Interregional NHS Treatment Free Text
CM P / C
Recommendations Free Text These recommendations do not include drug treatment (oxygen therapy, diet, limitations on physical exertion, etc.) CM AP / C
Drug Free Text (Specialty active + + dose / unit + No units / dose + dose range management + life + path) requirements to enable updated date. AP CM / C
+ MSPS Official List code (country code) / Snomed-CT To the extent that the implementation of EHR applications, including modules limitation, permit, free text will be replaced gradually by the vocabulary catalog of approved drugs (Official List / Snomed-CT) Nursing Diagnosis
assets
Text +
Code
+ Literal NANDA NANDA Code
The history contained in the date of last update
R
CM AP / C
Nursing Outcomes
Text +
Literal
NOC Code
+ NOC Code
Those selected results to identify the patient's progress as a result of planned interventions that provided in the story at the time of last update
CM
AP
R / C
speeches Nursing Text +
Literal
Code
+ NIC NIC
The history contained in the date of last update
CM
AP
R / C
ALERTS Free Text Your content should be an objective key warnings which by its special importance should be highlighted to be taken into account for any need professional attention (eg angioedema triggered by ACE inhibitors reservoir device IV) CM MP / C
subjective observations Professional Free Text The only justification for this field is to collect values \u200b\u200bof professionalism, provided they are of genuine concern for management of health problems other professional. Should only be reviewed those comments that are frame them in some of the following sections: RMP
• DIAGNOSTIC ASSESSMENTS NOT SHOWN ON ASSUMPTIONS
• ABOUT SUSPECTED VIOLATIONS OF THERAPEUTIC TREATMENTS
• SUSPECT NOT DECLARED
• NO KNOWN SUSPECT BEHAVIOR
• SUSPECTED TO HAVE BEEN A VICTIM OF ABUSE
• 14
unusual behavior can classify each country as their presence is deemed essential (though the completion of the value is not required) and should therefore be part of the minimum set of SNS (CM), or else, their presence is desirable but not essential as part of minimum data set (R).
15 data fields in the Medical Record Summary must be fed automatically, from digital health history, except a very small number of them will have to manually feed the professional M, in those cases where it it sees fit.
16 The field may be accessible, depending on the nature of their content (subjective or objective data entries), professionals or citizen C. P ANNEX IX
Alphabetical list of abbreviations used
Meaning Abbreviation Database
BDTSI individual health card
CIAP2 International Classification in primary care. Version 2
ICD-9-CM International Classification of Diseases. Clinical Modification
MDS CM minimum set record highs of General Hospitals NHS CNH
National Catalogue of Hospitals
LOINC Logical Observation Identifiers Names and Codes
MOH Ministry of Health and Social Policy
NANDA North American Nursing Diagnosis Association
NIC Nursing Interventions Classification Nursing Outcomes Classification NOC
R RECESS
Recommended General Register of Establishments and Health Services Department of the Ministry of Health and Social Policy
SERAM English Society of Medical Radiology
SEMN English Society of Nuclear Medicine Information System
SIFCO Cohesion Fund of SNOMED-CT SNS systematize
Nomenclature of Medicine-Clinical Terms
Carlos Gallego carlos@cgallego.es 
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