ID

37068

Description

PCORnet Common Data Model (CDM) Diagnosis Diagnosis codes indicate the results of diagnostic processes and medical coding within healthcare delivery. Data in this table are expected to be from healthcare-mediated processes and reimbursement drivers. PCORnet Common Data Model (CDM) The PCORnet Common Data Model (CDM) is a specification that defines a standard organization and representationof data for the PCORnet Distributed Research Network. The PCORnet CDM is a key component of the PCORnet Distributed Research Network (DRN) infrastructure. http://www.pcornet.org/pcornet-common-data-model/

Link

http://www.pcornet.org/pcornet-common-data-model/

Keywords

Versions (3)
  1. 12/10/16 12/10/16 -
  2. 7/1/19 7/1/19 -
  3. 3/30/20 3/30/20 -
Copyright Holder

PCORnet

Uploaded on

July 1, 2019

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License

Creative Commons BY-NC 3.0
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PCORnet Common Data Model (CDM)

English

Diagnosis V4.1

1 forms  
  1. StudyEvent: ODM
    1. Diagnosis V4.1
Diagnosis
Description

Diagnosis

Alias
UMLS CUI-1
C0011900
Diagnosis ID
Description

Arbitrary identifier for each unique record.

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C1300638
Patient ID
Description

Arbitrary person-level identifier. Used to link across tables. All PATIDs in this table must be present in the DEMOGRAPHIC table.

Data type

text

Alias
UMLS CUI [1]
C2348585
Encounter ID
Description

Arbitrary encounter-level identifier. Used to link across tables. All ENCOUNTERIDs in this table must be present in the ENCOUNTER table.

Data type

text

Alias
UMLS CUI [1,1]
C1512346
UMLS CUI [1,2]
C1300638
Encounter Type
Description

Please note: This is a field replicated from the ENCOUNTER table. See the ENCOUNTER table for definitions. Should be non-null for all records replicated from ENCOUNTER table (guidance added in v4.0).

Data type

text

Alias
UMLS CUI [1,1]
C1512346
UMLS CUI [1,2]
C0332307
Admit Date
Description

Please note: This is a field replicated from the ENCOUNTER table. See the ENCOUNTER table for definitions.

Data type

date

Alias
UMLS CUI [1,1]
C0030673
UMLS CUI [1,2]
C0011008
Provider ID
Description

Identifier associated with the provider most responsible for the diagnosis. The PROVIDERID from the ENCOUNTER can be used if provider assigning the diagnosis is unknown. Use the ID of the attending provider if the diagnosis is assigned by a resident/intern. All PROVIDERIDs must be present in the PROVIDER table.

Data type

text

Alias
UMLS CUI [1,1]
C1138603
UMLS CUI [1,2]
C1300638
DX
Description

Diagnosis code. Some codes will contain leading zeroes, and different levels of decimal precision may also be present. This field is a character field, not numeric, to accommodate these coding conventions. Please populate the exact textual value of this diagnosis code, but remove source- specific suffixes and prefixes. Other codes should be listed as recorded in the source data. Do not include leading zeros beyond those that are part of the code itself (i.e., represent ICD-9 diagnosis 001.9 as “001.9”, not “000001.9” or some other variation). Decimal points may or may not be present for ICD-9/ICD-10 codes. If the decimal point is missing from source data, do not add. If it is present in source data, do not remove.

Data type

text

Alias
UMLS CUI [1]
C1550350
DX Type
Description

Diagnosis code type. We provide values for ICD and SNOMED code types. Other code types will be added as new terminologies are more widely used. Please note: The “Other” category is meant to identify internal use ontologies and codes.

Data type

text

Alias
UMLS CUI [1,1]
C1550350
UMLS CUI [1,2]
C0332307
UMLS CUI [2]
C2598420
UMLS CUI [3]
C1136257
DX Source
Description

Classification of diagnosis source. We include these categories to allow some flexibility in implementation. The context is to capture available diagnoses recorded during a specific encounter. It is not necessary to populate interim diagnoses unless readily available. Ambulatory encounters would generally be expected to have a source of “Final.”

Data type

text

Alias
UMLS CUI [1,1]
C1550350
UMLS CUI [1,2]
C0449416
DX Origin
Description

Source of the diagnosis information. Billing pertains to internal healthcare processes and data sources. Claim pertains to data from the bill fulfillment, generally data sources held by insurers and other health plans. Use “OD” for diagnoses entered into the EHR that are associated with an Order. Use “OD” for any diagnosis associated with an encounter that is entered into the EHR by a provider. Use “BI” for all diagnoses that are generated through the physician and hospital billing process. Use “DR” for all diagnoses that are derived or imputed through analytical procedures (e.g., natural language processing). This does not apply to diagnoses that have been mapped from vocabulary mapping software/middleware (e.g., IMO) See General Guidance #4. In those instances, use “OD” or “BI”, depending on the provenance of the diagnosis.

Data type

text

Alias
UMLS CUI [1,1]
C1550350
UMLS CUI [1,2]
C0449689
PDX
Description

Value expected for IP, IS, EI, and OS encounters. May also be present for other encounter types. Principal discharge diagnosis flag. One principal diagnosis per encounter is expected, although in some instances more than one diagnosis may be flagged as principal. Professional vs. Facility – If a partner has access to both professional and facility diagnosis data for a given encounter, the facility diagnoses should be used to populate this field. Partners should document their approach in their ETL ADD.

Data type

text

Alias
UMLS CUI [1,1]
C0030685
UMLS CUI [1,2]
C0011900
DX POA
Description

Flag to denote whether diagnosis was present on inpatient admission. Y = Diagnosis present at time of inpatient admission N = Diagnosis not present at time of inpatient admission U = Documentation insufficient to determine if the condition was present at the time of inpatient admission W = Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission 1 = Unreported / not used. Exempt from present-on-admission reporting. Include for EI, IP visits only. If data are populated for some inpatient diagnoses, but not all, use “UN” for diagnoses with blank/null value. Only assign a value of “1” to a diagnosis if it is reported that way in the source system.

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
UMLS CUI [1,3]
C0030673
RAW DX
Description

Optional field for originating value of field, prior to mapping into the PCORnet CDM value set.

Data type

text

Alias
UMLS CUI [1,1]
C1550350
UMLS CUI [1,2]
C0205313
RAW DX Type
Description

Optional field for originating value of field, prior to mapping into the PCORnet CDM value set.

Data type

text

Alias
UMLS CUI [1,1]
C0205313
UMLS CUI [1,2]
C1550350
UMLS CUI [1,3]
C0332307
UMLS CUI [2]
C2598420
UMLS CUI [3]
C1136257
RAW DX Source
Description

Optional field for originating value of field, prior to mapping into the PCORnet CDM value set.

Data type

text

Alias
UMLS CUI [1,1]
C1550350
UMLS CUI [1,2]
C0449416
UMLS CUI [1,3]
C0205313
RAW PDX
Description

Optional field for originating value of field, prior to mapping into the PCORnet CDM value set.

Data type

text

Alias
UMLS CUI [1,1]
C0030685
UMLS CUI [1,2]
C0011900
UMLS CUI [1,3]
C0205313
RAW DX POA
Description

Field for originating value, prior to mapping into the PCORnet CDM value set.

Data type

text

Alias
UMLS CUI [1,1]
C0011900
UMLS CUI [1,2]
C0150312
UMLS CUI [1,3]
C0030673
UMLS CUI [1,4]
C0205313
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Similar models

Diagnosis V4.1

1 forms
  1. StudyEvent: ODM
    1. Diagnosis V4.1
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Diagnosis
C0011900 (UMLS CUI-1)
Diagnosis ID
Item
Diagnosis ID
text
C0011900 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Patient ID
Item
Patient ID
text
C2348585 (UMLS CUI [1])
Encounter ID
Item
Encounter ID
text
C1512346 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
Item
Encounter Type
text
C1512346 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Encounter Type
Code List
Encounter Type
CL Item
Ambulatory Visit (AV)
CL Item
Emergency Department  (ED)
CL Item
Emergency Department Admit to Inpatient Hospital Stay (permissible substitution)  (EI)
CL Item
Inpatient Hospital Stay  (IP)
CL Item
Non-Acute Institutional Stay  (IS)
CL Item
Observation Stay (OS)
CL Item
Institutional Professional Consult (permissible substitution) (IC)
CL Item
Other Ambulatory Visit  (OA)
CL Item
No information  (NI)
CL Item
Unknown  (UN)
CL Item
Other (OT)
Admit Date
Item
Admit Date
date
C0030673 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Provider ID
Item
Provider ID
text
C1138603 (UMLS CUI [1,1])
C1300638 (UMLS CUI [1,2])
DX
Item
DX
text
C1550350 (UMLS CUI [1])
Item
DX Type
text
C1550350 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
C2598420 (UMLS CUI [2])
C1136257 (UMLS CUI [3])
DX Type
Code List
DX Type
CL Item
ICD-9-CM (09)
CL Item
ICD-10-CM  (10)
CL Item
ICD-11-CM (11)
CL Item
SNOMED CT  (SM)
CL Item
No information  (NI)
CL Item
Unknown (UN)
CL Item
Other (OT)
Item
DX Source
text
C1550350 (UMLS CUI [1,1])
C0449416 (UMLS CUI [1,2])
DX Source
Code List
DX Source
CL Item
Admitting  (AD)
CL Item
Discharge  (DI)
CL Item
Final (FI)
CL Item
Interim  (IN)
CL Item
No information  (NI)
CL Item
Unknown (UN)
CL Item
Other (OT)
Item
DX Origin
text
C1550350 (UMLS CUI [1,1])
C0449689 (UMLS CUI [1,2])
DX Origin
Code List
DX Origin
CL Item
Order/EHR (OD)
CL Item
Billing (BI)
CL Item
Claim (CL)
CL Item
No information (NI)
CL Item
Unknown (UN)
CL Item
Other (OT)
CL Item
Derived  (DR)
Item
PDX
text
C0030685 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
PDX
Code List
PDX
CL Item
Principal (P)
CL Item
Secondary (S)
CL Item
No information (NI)
CL Item
Unknown (UN)
CL Item
Other (OT)
Item
DX POA
text
C0011900 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
C0030673 (UMLS CUI [1,3])
DX POA
Code List
DX POA
CL Item
Diagnosis present (Y)
CL Item
Diagnosis not present U = Insufficient documentation (N)
CL Item
Clinically undetermined (W)
CL Item
Unreported / not used NI=No information UN=Unknown (1)
CL Item
Other (OT)
RAW DX
Item
RAW DX
text
C1550350 (UMLS CUI [1,1])
C0205313 (UMLS CUI [1,2])
RAW DX Type
Item
RAW DX Type
text
C0205313 (UMLS CUI [1,1])
C1550350 (UMLS CUI [1,2])
C0332307 (UMLS CUI [1,3])
C2598420 (UMLS CUI [2])
C1136257 (UMLS CUI [3])
RAW DX Source
Item
RAW DX Source
text
C1550350 (UMLS CUI [1,1])
C0449416 (UMLS CUI [1,2])
C0205313 (UMLS CUI [1,3])
RAW PDX
Item
RAW PDX
text
C0030685 (UMLS CUI [1,1])
C0011900 (UMLS CUI [1,2])
C0205313 (UMLS CUI [1,3])
RAW DX POA
Item
RAW DX POA
text
C0011900 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
C0030673 (UMLS CUI [1,3])
C0205313 (UMLS CUI [1,4])
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