PCORnet Common Data Model (CDM)

Descrição

Arbitrary identifier for each unique record.

Tipo de dados

text

Alias

UMLS CUI [1,1]

C0011900

UMLS CUI [1,2]

C1300638

Descrição

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

Tipo de dados

text

Alias

UMLS CUI [1]

C2348585

Descrição

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

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1512346

UMLS CUI [1,2]

C1300638

Descrição

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).

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1512346

UMLS CUI [1,2]

C0332307

Descrição

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

Tipo de dados

date

Alias

UMLS CUI [1,1]

C0030673

UMLS CUI [1,2]

C0011008

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1138603

UMLS CUI [1,2]

C1300638

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI [1]

C1550350

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1550350

UMLS CUI [1,2]

C0332307

UMLS CUI [2]

C2598420

UMLS CUI [3]

C1136257

Descrição

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.”

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1550350

UMLS CUI [1,2]

C0449416

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1550350

UMLS CUI [1,2]

C0449689

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI [1,1]

C0030685

UMLS CUI [1,2]

C0011900

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI [1,1]

C0011900

UMLS CUI [1,2]

C0150312

UMLS CUI [1,3]

C0030673

Descrição

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

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1550350

UMLS CUI [1,2]

C0205313

Descrição

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

Tipo de dados

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

Descrição

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

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1550350

UMLS CUI [1,2]

C0449416

UMLS CUI [1,3]

C0205313

Descrição

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

Tipo de dados

text

Alias

UMLS CUI [1,1]

C0030685

UMLS CUI [1,2]

C0011900

UMLS CUI [1,3]

C0205313

Descrição

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

Tipo de dados

text

Alias

UMLS CUI [1,1]

C0011900

UMLS CUI [1,2]

C0150312

UMLS CUI [1,3]

C0030673

UMLS CUI [1,4]

C0205313