Medical Alert Information
History of Past Illness
Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
text
Diagnosis
text
Problem Status
integer
Problem Severity
integer
Date of problem onset
date
Problem resolution date
date
Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
text
Describes the type of procedure that has been executed as part of the healthcare event.
text
Procedure Id (code)
integer
Date when procedure was performed
date
Social History
Social History Observations
text
Date range of observation
text
Pregnancy History
Vaccination
Brand name of the vaccination
text
Description of the vaccine
text
The code of the vaccine
integer
The date the vaccination was done
date
Medical Devices and Implants
Describes the patient's implanted and external medical devices and equipment that their health status depends on. Includes devices as cardiac pacemakers, implantable defribillator, prothesis, feromagnetic bone implants etc that are important to be known by HP.
text
Device Code
text
Implant date
date
Medical problems (current)
Problems or diagnosis not included under the definition of ‘Current problems or diagnosis’. Example: hepatic cyst (the patient has been treated with an hepatic cystectomy that solved the problem and therefore it ́s a closed problem)
text
Diagnosis
text
Problem Status
integer
Problem Severity
integer
Date of problem onset
date
Problem resolution date
date
Describes the reason by which the problem changed the status from current to inactive (e.g. surgical procedure, medical treatment, etc). This field includes ‘free text’ if the resolution circumstances are not already included in other fields. Example: It can happen that this field is already included in other like Surgical Procedure, medical device etc, eg: hepatic cystectomy (this wil be the ‘Resolution Circumstances’ for the problem ‘hepatic cyst’ and will be included in surgical procedures)
text
Describes the type of procedure that has been executed as part of the healthcare event.
text
Procedure Id (code)
integer
Date when procedure was performed
date
Vital Signs Observations
Systolic
integer
Diastolic
integer
Date when blood pressure was measured
date
Diagnostic Tests
Result of Blood Group
text
Disability or function
Need of the patient to be continuously assisted by third parties. Invalidity status may influence decisions about how to administer treatments
text
Invalidity code
text
Date of invalidity onset
date
Medication
Surgical Procedure
Describes the type of procedure that has been executed as part of the healthcare event.
text
Procedure Id (code)
integer
Date when procedure was performed
date
Treatments
Treatment description
text
Code system not yet specified
text
Date of treatment onset
date
Care plan
Therapeutic recommendations that do not include drugs (diet, physical exercise constraints, etc.)
text
Code system not yet specified
text