Based on SHR [1]:
● Allergy recent occurrence, irritant, reactions, ...
● Behavior alcohol use, diet followed, exercise hours per week, drug use, sleep quality, …
● Careplan care team, goal, objective, planned activities, ...
● Condition onset, when clinically recognized, disease progression, …
● Core (demographic, identification) address, age, name, ...
● Device device used, implanted, vendor model number, ...
● Encounter payment source, referral date, service given, service provider, ...
● Careplan care team, goal, objective, planned activities, ...
● Environment financial situation, home environment risk, household size, income source,
annual income, ...
● Family history family member condition, ...
● Financial coverage, insurance member ID
● Immunization immunizations given, immunizations not given, vaccines, …
● Life history employment, educational attainment, military status, occupation, travel, ...
● Medication medication, dosage, number of refills allowed, amount per dose,
administration method, ...
● Oncology TNM stage, breast cancer genetic analysis, tumor dimension size, estrogen
receptor status, ...
● Procedure lab procedure performed, specimen collection performed, surgical approach,
surgical procedure, ...
● Research sponsor, study arm, principal investigator, …
● Vital blood pressure, body height, body mass index, body weight, heart rate, respiratory
rate, ...
Additional sections [2]:
● Imaging x-ray
● Directive
● Surgical history dates of operations, operative reports, …
● Pathology biopsy results, ...
● Obstetric history prior pregnancies, complications of prior pregnancies, ...
● Test results blood tests, imaging, pathology, …
References