HL7 v2 Data Requirements and Pre-work - WVHIN
HL7 v2 Data Requirements and Pre-workHospital/Provider Name, STParticipant Pre-workAudience:The Executive Sponsor, Project Manager, End User, and EHR Interface Engineer should collaborate to complete the Pre-work and Coded Values sections of this document.Pre-work Instructions:Please complete the questions on this page regarding system information, historical data backload, and sensitive health data. Also, please complete the Coded Values section at the end of this document.System Information:Please list all unique source system vendor names and versions:Are patient IDs unique across all source systems?Are visit IDs unique across all source systems?Do your systems support patient merges (ex. ADT-A18, ADT-A34)?Do your systems support account merges (ex. ADT-A18, ADT-A34)?Will you be implementing Trusted Application Integration?Historical Data Backload:Will you be providing a historical data backload? If yes, please specify timeframe (2 to 3 years):Please specify format of data backload (i.e. HL7, flat file):Sensitive Health Data:The WVHIN system has the capability to flag certain codes and criteria as sensitive. Visibility will be based on user-access policies applied at the end-user level. The WVHIN’s policy on Patient Consent – Sensitive Health Information can be found here.Following the kick-off call, the Truven Health project manager assigned to your on-boarding project will provide technical guidelines for your security officer to review and acknowledge.HL7 v2 Data Requirements – WVHIN TOC \o "1-4" \h \z \u HL7 v2 Data Requirements by Segment Specification PAGEREF _Toc404261814 \h 41)MSH Segment Specification (Message Header) - Required PAGEREF _Toc404261815 \h 42)PID Segment Specification (Patient Identification) - Required PAGEREF _Toc404261816 \h 43)NK1 Segment Specification (Next of Kin) - Optional PAGEREF _Toc404261817 \h 54)PV1 Segment Specification (Patient Visit) - Required PAGEREF _Toc404261818 \h 55)DG1 Segment Specification (Patient Diagnoses) - Required PAGEREF _Toc404261819 \h 66)PR1 Segment Specification (Procedures Segment) - Desired PAGEREF _Toc404261820 \h 77)IN1/IN2 Segment Specification (Insurance Segment) - Desired PAGEREF _Toc404261821 \h 78)Orders - Required PAGEREF _Toc404261822 \h 89)Discrete Observations - Required PAGEREF _Toc404261823 \h 910)Observation Groups - Required PAGEREF _Toc404261824 \h 911)Observation Results - Required PAGEREF _Toc404261825 \h 1012)Medication Orders - Required PAGEREF _Toc404261826 \h 1113)Medication Components - Required PAGEREF _Toc404261827 \h 1214)Medications Administered - Desired PAGEREF _Toc404261828 \h 1315)Report Text - Optional PAGEREF _Toc404261829 \h 1416)Problems - Required PAGEREF _Toc404261830 \h 1417)Allergies - Required PAGEREF _Toc404261831 \h 1418)Specimens - Optional PAGEREF _Toc404261832 \h 15Coded Values PAGEREF _Toc404261833 \h 161)Facility Codes PAGEREF _Toc404261834 \h 162)Allergen Type Code PAGEREF _Toc404261835 \h 163)Allergen Severity Code PAGEREF _Toc404261836 \h 164)Observations Result Status Code PAGEREF _Toc404261837 \h 165)Abnormal Flag Code PAGEREF _Toc404261838 \h 176)Diagnosis Type Code PAGEREF _Toc404261839 \h 187)Diagnosis Coding System Code PAGEREF _Toc404261840 \h 188)Diagnosis Priority PAGEREF _Toc404261841 \h 189)Present on Admission Indicator Code PAGEREF _Toc404261842 \h 1910)Procedure Coding System Type Code PAGEREF _Toc404261843 \h 1911)Problem Action Code PAGEREF _Toc404261844 \h 1912)Patient Class Code PAGEREF _Toc404261845 \h 2013)Admission Type Code PAGEREF _Toc404261846 \h 2014)Admission Source Code PAGEREF _Toc404261847 \h 2015)Race PAGEREF _Toc404261848 \h 2116)Ethnicity PAGEREF _Toc404261849 \h 2117)Gender PAGEREF _Toc404261850 \h 2118)Plan Type Code PAGEREF _Toc404261851 \h 2219)Discharge Disposition Code PAGEREF _Toc404261852 \h 2320)Marital Status Code PAGEREF _Toc404261853 \h 25HL7 v2 Data Requirements by Segment SpecificationPlease review the Default HL7 Locations, Field Name, and Standard Description as it applies to your healthcare facility or healthcare system. Bolded fields contain Coded Values. Please refer to the Coded Values section at the end of this document to specify Hospital/Clinic Values.MSH Segment Specification (Message Header) - RequiredDefault HL7 LocationField NameStandard Description MSH.3Sending ApplicationName of application that sent HL7 messageMSH.4Sending FacilityName of healthcare facility that sent HL7 messageMSH.9.1Message CodeHL7 message type, (e.g., ADT, ORU, etc.)MSH.9.2Event Type CodeHL7 event type (e.g., A01, A08, etc.)MSH.10Message Control NumberMessage Control ID assigned by sending applicationPID Segment Specification (Patient Identification) - RequiredDefault HL7 LocationField NameStandard Description PID.3.1Local Patient NumberIdentifier used by healthcare facility to uniquely identify a patient. Also referred to as Medical Record Number.PID.4.1Unique Patient NumberOptional identifier used to uniquely identify a patient across facilities within a hospital system. Also referred to as the Unique Patient Identifier.PID.5.1Last NameLast name of patientPID.5.2First NameFirst name of patientPID.5.3Middle NameMiddle name (or initial) of patientPID.7Birth Date/TimePatient's date of birthPID.8Gender CodePatient's genderPID.10Race CodePatient's racePID.11.1Street Address 1First line of street address of patient's mailing addressPID.11.2Street Address 2Second line of street address of patient's mailing addressPID.11.3Address CityCity of patient's mailing addressPID.11.4Address StateState of patient's mailing addressPID.11.5Address ZipZip codePID.11.6Address CountryCountry of patient's mailing addressPID.12Address CountyCounty of patient's mailing addressPID.13Home PhonePatient's home phone numberPID.14Business PhonePatient's business phone numberPID.15.2Primary LanguagePrimary language spoken by patientPID.16Marital Status CodePatient's marital statusPID.17Religion CodePatient's religionPID.18Visit NumberUnique number assigned to each patient visit across facilities and systems. Also referred to as Patient Account Number or Episode of Care ID. Must be present in PID.18 or PV1.19.PID.19SSNPatient’s Social Security NumberPID.22Ethnic Group CodePatient's ethnic group codePID.30Death Indicator CodeField indicates whether he patient is deceased. Valid values are Y and N.MRG.1.1Prior Patient NumberUsed only in patient merge messages, this field contains prior patient identifier. Also referred to as the Med Prior Patient Identifier.NK1 Segment Specification (Next of Kin) - OptionalDefault HL7 LocationField NameStandard Description NK1.2.1Last NameLast name of patient’s next of kinNK1.2.2First NameFirst name of patient’s next of kinNK1.2.3Middle NameMiddle name (or initial) of patient’s next of kinNK1.3RelationshipRelationship of next of kin to patientNK1.4.1Street Address 1First line of street address of next of kin's mailing addressNK1.4.2Street Address 2Second line of street address of next of kin's mailing addressNK1.4.3Address CityCity of next of kin's mailing addressNK1.4.4Address StateState of next of kin's mailing addressNK1.4.5Address ZipZip code of next of kin's mailing addressNK1.4.6Address CountryCountry of next of kin's mailing addressNK1.4.9Address County CodeCounty of next of kin's mailing addressNK1.5Home PhoneNext of kin's home phone numberNK1.6Business PhoneNext of kin's business phone numberPV1 Segment Specification (Patient Visit) - RequiredDefault HL7 LocationField NameStandard Description PV1.2Patient Class CodeUsed to categorize patients (inpatient, outpatient, emergency, obstetrics, etc)PV1.3.1Point of CareDescription of patient's assigned location, or location to which patient is being moved. Also known as ward or unit.PV1.3.2RoomPatient's assigned room, or the room to which patient is being movedPV1.3.3BedPatient's assigned bed, or the bed to which patient is being movedPV1.4Admission Type CodeCircumstances under which patient was or will be admittedPV1.7.1Attending DoctorPV1.8.1Referring DoctorPV1.9.1Consulting DoctorPV1.10Hospital ServiceTreatment or type of surgery that patient is scheduled to receive (e.g., cardiac, medical, pulmonary, etc)PV1.14Admission Source CodeIndicates where patient was admittedPV1.16VIP IndicatorSite-specific value indicating if the patient is a VIPPV1.17.1Admitting DoctorPV1.18Patient TypeSite-specific values that identify patient typePV1.19Visit NumberUnique number assigned to each patient visit across facilities and systems. Also referred to as Patient Account Number or Episode of Care ID. Must be present in PID.18 or PV1.19.PV1.20.1Financial ClassSite-specific values that identify financial class(es) assigned to patient for purpose of identifying sources of reimbursementPV1.20.2Financial Class Effective Date/TimeEffective date of Financial ClassPV1.36Discharge Disposition CodeContains disposition of patient at time of dischargePV1.37.1Discharge To LocationHealthcare facility to which patient was dischargedPV1.37.2Discharge To Location Date/TimeDischarge date associated with Discharged To Location CodePV1.44Admit Date/TimeAdmit date/timePV1.45Discharge Date/TimeDischarge date/timePV1.52.1Other Healthcare ProviderPV2.3Reason for VisitShort description of the reason for patient visitPV2.38Mode of ArrivalSite-specific code indicating how patient was brought to healthcare facility (i.e. ambulance, car, etc)PV2.40Admission Level of CareIndicates acuity level assigned to patient at time of admission (e.g., acute, chronic, critical)PD1.4.1Patient Primary Care ProviderMRG.3Prior Visit NumberUsed only in visit merge messages, this field contains prior visit identifierDG1 Segment Specification (Patient Diagnoses) - RequiredDefault HL7 LocationField NameStandard Description DG1.3.1Diagnosis CodeUniquely identifies a particular diagnosis. This element may conform to some external, standard coding system or it may be local code or free textDG1.3.2Diagnosis DescriptionDescription supplied by hospital for Diagnosis CodeDG1.3.3Diagnosis Coding System CodeCoding system used in Diagnosis Code field (e.g., ICD9, ICD10 or Snomed CT)DG1.5Diagnosis Date/TimeDate/time that diagnosis was determinedDG1.6Diagnosis Type CodeIdentifies type of diagnosis being sent (i.e., admitting, working or final)DG1.15Diagnosis PriorityIdentifies significance or priority of diagnosis codeDG1.26Present on Admission Indicator CodePresent on Admission indicator for this particular diagnosis. Reimbursement formulas for some states and Medicare have mandated that each diagnosis code be flagged as to whether it was present on admission or not.PR1 Segment Specification (Procedures Segment) - DesiredDefault HL7 LocationField NameStandard Description PR1.3.1Procedure CodeUniquely identifies a particular procedure. This element may conform to some external, standard coding system or it may be local code or free text.PR1.3.2Procedure DescriptionDescription supplied by hospital for Procedure CodePR1.3.3Procedure Coding System Type CodeCoding system used in Procedure Code field (e.g., ICD9 or CPT)PR1.14Procedure PriorityNumber that identifies significance or priority of procedure codePR1.16Procedure Code ModifierProcedure code modifier to Procedure Code, when applicableIN1/IN2 Segment Specification (Insurance Segment) - DesiredDefault HL7 LocationField NameStandard Description IN1.2.1Plan NumberSite-specific identifier for insurance planIN1.2.2Plan NameName of insurance planIN1.3Company NumberSite-specific identifier for insurance companyIN1.36Insured's Policy NumberIndividual policy number of insured to identify patient's planIN1.4Company NameName of insurance companyIN1.45Verification StatusStatus of patient's relationship with insurance carrierIN1.5.1Company StreetStreet of insurance company's mailing addressIN1.5.3Company CityCity of insurance company's mailing addressIN1.5.4Company StateState of insurance company's mailing addressIN1.5.5Company ZipZip code of insurance company's mailing addressIN1.5.6Company CountryCountry of insurance company's mailing addressIN1.7Company PhonePhone number of insurance companyIN1.8Group NumberGroup number of insured's insuranceIN1.9Group NameGroup name of insured's insuranceIN1.11Employer NameName of employer that provides employee's insuranceIN1.15Plan Type CodeIdentifies type of health insurance planIN2.6Medicare Health Insurance Card NumberMedicare Health Insurance Card Number (HIN), as defined by CMS or other regulatory agencies.Orders - RequiredThe Orders section contains fields that describe non-medication orders. An order is a request for material or services, usually for a specific patient. Examples include orders for clinical observations (e.g., vitals, I&Os) from the nursing service, tests in the laboratory, food from dietary, films from radiology, etc. There may be multiple orders per message.Default HL7 LocationField NameStandard Description ORC.1Order Control CodeDescribes function of order segment within messageORC.3.1Filler Order NumberIdentification number that is assigned by application that filled orderORC.2.1Placer Order NumberIdentification number that is assigned by application that placed orderORC.3.1Unique Order NumberUnique identification number for medication order. This may be Filler Order Number, Placer Order Number, or concatenation of the twoOBR.4.1Service CodeUniquely identifies particular type of order (e.g., an order for a specific lab test. This element may conform to some external, standard coding system or it may be local code.OBR.4.3Service Coding SystemCoding system used in Service CodeOBR.4.2Service NameDescription supplied by hospital for Service CodeORC.7.1QuantityNumeric quantity of service that should be provided at each service interval. For example, if two blood cultures are to be obtained every 4 hours quantity would be "2".ORC.7.2IntervalInterval at which order should be performed (e.g., "daily")ORC.7.3DurationDuration of order (e.g., "for 3 days")ORC.7.4Start Date/TimeExplicit start date and time for medication orderOBR.7.5End Date/TimeExplicit end date and time for medication orderORC.7.6PriorityPriority of request (e.g., stat or routine)ORC.7.7ConditionFree text field that describes condition under which service should be performed. Also known as PRN.ORC.9Transaction Date/TimeDate and time of event that initiated current transaction, as defined in Order Control CodeORC.16Order Control Code ReasonExplanation of reason for order event described by Order Control Code. This field may be either coded or free text form.MSH.3CategoryType of order (e.g., lab order or microbiology order)NTE.3NoteAny free text notes associated with lab orderOBR.16.1Caregiver NumberHealthcare facility's identification code for provider who ordered material or serviceOBR.16.2Last NameOrdering provider's last nameOBR.16.3First NameOrdering provider's first nameDiscrete Observations - Required The Discrete Observations section contains fields that describe observations related to an order. These observations may include unstructured notes such as the reason for exam, or more structured comments related to a specific type of order. There may be multiple order observations per order.Default HL7 LocationField NameStandard Description OBX.1Sequence NumberSequence number of this observation within order messageORC.3.1Order Unique Order NumberUnique identification number for order, repeated from Orders Unique Order Number field.OBX.3.1Observation Type CodeUniquely identifies a particular type of observation within order message. This element may confirm to some external, standard coding system or it may be local code or free text.OBX.3.2Observation Type NameDescription supplied by hospital for Observation Type CodeOBX.3.3Observation Type Coding SystemCoding system used in Observation Type CodeOBX.5Observation ValueValue provided in this observation (e.g., textual description of reason for a radiology exam)NTE.3NoteAny free text notes associated with order observationObservation Groups - RequiredThe Observation Groups section contains identifiers and other fields related to a group of observations, i.e., lab, vitals or microbiology results. There may be multiple observation groups per message.Default HL7 LocationField NameStandard Description OBR.1Sequence NumberSequence number of this observation within messageOBR.2.1Placer Order NumberIdentification number assigned by application that placed medication orderOBR.3.1Filler Order NumberIdentification number assigned by application that filled lab orderOBR.3.1Unique Order NumberUnique identification number for order. May be Filler Order Number, Placer Order Number, or concatenation of the twoOBR.4.1Service CodeUniquely identifies particular type of observation. This element may conform to some external, standard coding system or may be a local codeOBR.4.2Service NameDescription supplied by hospital for Observation Type CodeOBR.4.3Service Coding SystemCoding system used in Service CodeOBR.7.1Observation Date/TimeIn the case of observations taken directly from a subject, this is actual date and time observation was obtained. In the case of specimen-associated study, this represents date and time specimen was collected or obtainedOBR.16.1Caregiver NumberHealthcare facility's identification number for provider who ordered observationOBR.16.2Last NameOrdering provider's last nameOBR.16.3First NameOrdering provider's first nameOBR.22Observation Report Status Date/TimeDate and time results are composed into report andreleased, or that a status, or defined in Order Status, is entered or changedOBR.25Result Status CodeStatus of results for this orderNTE.3NoteAny free text notes associated with the vital signs observation resultsObservation Results - RequiredThe Observation Results section contains information about the results of an observation such as a lab test or vital sign. There may be multiple observation results per message.Default HL7 LocationField NameStandard Description OBX.1Sequence NumberSequence number of lab result (within message)OBR.3.1Observation Group Unique Order NumberUnique identification number for order, repeated from Observation Group Unique Order NumberOBX.3.1Observation Type CodeUniquely identifies particular type of observation.This element may confirm to some external, standard coding system or may be local code or free textOBX.3.2Observation Type NameDescription supplied by hospital for Observation Type CodeOBX.3.3Observation Type Coding System CodeCoding system used in Observation Type CodeOBX.5Observation ValueHospital-supplied value for observationOBX.6Observation UnitsHospital-supplied unit of measure for Observation ValueOBX.7Reference RangeNormal range for specific numeric laboratory result valueOBX.8Abnormal Flag CodeCode indicating normalcy status of resultOBX.11Result Status CodeStatus of results for this orderOBX.14Observation Date/TimeIn the case of observations taken directly from a subject, this is actual date and time observation was obtained. In the case of specimen-associated study, this represents date and time specimen was collected or obtainedNTE.3NoteAny free text notes associated with lab or vitals observation resultMedication Orders - RequiredThe Medication Orders section contains fields that describe a medication order. There may be multiple medication orders per message.PLEASE NOTE: RXO (non-encoded order) segments are supported in addition to RXE segments and RXR segments.Default HL7 LocationField NameStandard Description ORC.1Order Control CodeDescribes function of order segment within message (e.g. "NW" (new) or "CA" (cancel order)ORC.2Placer Order NumberIdentification number assigned by application that placed medication orderORC.3Filler Order NumberIdentification number assigned by application that filled medication orderORC.3Unique Order NumberUnique identification number for medication order. This may be Filler Order Number, Placer Order Number, or a concatenation of the two.ORC.5Order Status CodeDescribes status of order (e.g., completed, discontinued, etc.)ORC.9Transaction Date/TimeDate and time of event that initiated current transaction, as defined in Order Control CodeORC.12.1Caregiver NumberHealthcare facility's identification number for provider who ordered medicationORC.12.2Last NameOrdering provider's last nameORC.12.3First NameOrdering provider's first nameRXE.1.1QuantityNumeric quantity of medication that should be provided at each service intervalRXE.1.2IntervalInterval at which medication should be provided (e.g., “every 4 hours”)RXE.1.3DurationDuration of medication order (e.g., "for 3 days")RXE.1.4Start Date/TimeExplicit start date and time for medication orderRXE.1.5End Date/TimeExplicit end date and time for medication orderRXE.1.6PriorityPriority of request (e.g., stat or routine)RXE.1.7ConditionCondition on which medication should be given (e.g., "as needed for pain". Also known as PRN)RXE.3Minimum DoseOrdered amount as encoded by pharmacy or treatment supplier. In variable dose order, this is minimum order amount. In non-varying dose order, this is exact amount of orderRXE.4Maximum DoseIn variable dose order, this is maximum ordered amount. In non-varying dose, field not usedRXE.5.1Dose UnitsUnits for Minimum Dose and Maximum Dose fieldsRXE.7.2Provider Administration InstructionsOrdering provider's instructions to patient or provider administering drugRXE.21Supplier Administration InstructionsPharmacy or treatment supplier's provider-generated special instructions to provider dispensing/administering orderRXE.23Dose Rate AmountRate at which substance should be administeredRXE.24Dose Rate UnitsUnits for Dose Rate AmountRXR.1.1RouteSite-specific route of administration from medication orderNTE.3NoteAny additional free text notes associated with medication orderedMedication Components - RequiredThe Medication Components section contains fields that describe the components of an ordered medication. There should always be at least one component per medication, and there can be multiple components, e.g. for IV medications. Note that medication component information may be provided in the RXE and/or the RXC segments of an HL7 message.PLEASE NOTE: RXO (non-encoded order) segments are supported in addition to RXE segments and RXC segments.Default HL7 LocationField NameStandard Description RXE.2.1 orRXC.2.1Component CodeUniquely identifies medical substance or treatment ordered. This element may confirm to some external, standard coding system or it may be a local code or free textRXE.2.2 orRXC.2.2Component NameDescription supplied by hospital for Component CodeRXE.2.3 orRXC.2.3Component Coding SystemCoding system used in Component CodeRXE.10 orRXC.3Component AmountAmount to be dispensed, as encoded by pharmacy or treatment supplierRXE.11 orRXC.4Component UnitsContains units for Component Amount as encoded by pharmacy or treatment supplierRXE.31.1 orRXC.7.1Supplementary CodeField accommodates identification of any additional codes supplied in HL7 message that might be associated with pharmaceutical substance. Common codes include Generic Product Identifier (GPI), Generic Coe Number_Sequence Number (GCN_SEQNO), and National Drug Code (NDC).RXE.31.2 orRXC.7.2Supplementary NameDescription supplied by hospital for Supplementary CodeRXE.31.3 orRXC.7.3Supplementary Coding SystemCoding system used in Supplementary Code Medications Administered - DesiredThe Medications Administered section contains fields that describe the administration of a medication order. There may be multiple Medications Administered per order (one for each administration).Default HL7 LocationField NameStandard Description RXA.2Administration CounterStarts with ‘1’ first time that medication/treatment is administered for this order, and increments by one with each additional administration of medication/treatmentRXA.3Administration Start Date/TimeDate and time administration of medication was startedRXA.4Administration End Date/TimeDate and time administration of medication was endedRXA.5.1Medication CodeSite-specific identifier of medical substance/treatmentadministeredRXA.5.2Medication NameDescription supplied by hospital for Medication CodeRXA.5.3Medication Coding SystemCoding system used in Medication CodeRXA.6Administered AmountContains amount administeredRXA.7Administered UnitsMust be in simple units that reflect actual quantity of substance administered. Does not include compound unitsRXA.9.2Administration NotesNotes from provider administering medication/treatmentRXA.18Refusal ReasonReason patient refused medical substance/treatment. Any entry in field indicates patient did not take substanceRXA.20Completion StatusSite-specific status of treatment administration event (i.e., completed, refused, not administered)RXR.1.1RouteSite-specific code for route by which medication was administeredNTE.3NoteAny free text notes associated with medication administeredReport Text - OptionalThe Report Text section contains fields from a message with unstructured text such as nursing notes, pathology reports, radiology reports, or transcribed reports. There may be multiple report text sections per message.Default HL7 LocationField NameStandard Description OBR.3.1Observation Group Unique Order NumberUnique identification number for report, repeated from Observation Group Unique Order NumberOBR.4.2Report Text HeaderBrief text that describes report (e.g., "CHEST PA LAT")OBX.5Report Text BodyBody of text report. Note that if message contains multiple result segments, OBX.5 values from all OBXs for specific OBR will be concatenated together, with /n as delimiterNTE.3NoteAny free text notes associated with report text componentProblems - RequiredThe Problem Reports section contains fields that are used to describe the patient's acute and chronic problems, as tracked in a longitudinal patient record. Problems may span multiple visits or encounters.Default HL7 LocationField NameStandard Description PRB.1Action CodeCode that describes intent of messagePRB.2Action Date/TimeDate/time that operation represented by action code was performedPRB.3.1Problem CodeIdentifies type of problem, from institution's master list of problems. Element may conform to some external, standard coding system or it may be local code or free textPRB.3.2Problem DescriptionDescription supplied by hospital for Problem CodePRB.3.3Problem Coding System CodeCoding system used in Problem Code fieldPRB.4.1Problem NumberIdentifier assigned by initiating system to instance of problemPRB.7Problem Established Date/TimeDate/time when corresponding problem initially identified by caregiverPRB.9Actual Problem Resolution Date/TimeDate/time that problem actually resolvedPRB.12Problem PersistencePerseverance of problem (e.g., acute, chronic, etc.)PRB.14.1Problem Life Cycle StatusCurrent status of problem (e.g., active, active-improving, active-stable, active worsening, inactive, resolved, etc.)PRB.16Problem Onset Date/TimeDate/time when problem beganNTE.3NoteAny free text notes associated with problemAllergies - RequiredThe Allergies section contains fields that describe the patient's allergies. There may be multiple allergies per patient. Note that allergy information may be provided in either the AL1 or IAM segment of an HL7 message.Default HL7 LocationField NameStandard Description AL1.2 orIAM.2Allergen Type CodeGeneral allergy category (drug, food, pollen, etc.)AL1.3.1 orIAM.3.1Allergen CodeUniquely identifies particular allergen. Element may conform to some external, standard coding system or it may be local code or free textAL1.3.2 orIAM.3.2Allergen DescriptionDescription supplied by hospital for Allergen CodeAL1.3.3 orIAM.3.3Allergen Coding System CodeCoding system used in Allergen Code fieldAL1.4 orIAM.4Allergy SeveritySite-specific value that indicates general severity of allergy (e.g. mild, moderate, severe, etc.)AL1.5 orIAM.5Allergy ReactionSite-specific value that indicates specific allergic reaction documented (i.e., itching, nausea, etc.)AL1.6 orIAM.11Onset Date/TimeDate and time allergy was identifiedIAM.6.1Allergy Action CodeDefines status of record, (e.g., add/insert, update, delete). Allows hospitals to send allergy messages that delete or update previously sent allergy messages.Specimens - OptionalThe Specimens section contains fields that describe the specimen that was tested as part of a microbiology test or lab order. There may be multiple specimens per message. Completion of this section is not required if specimens data will not be sent in HL7 messages.Default HL7 LocationField NameStandard Description SPM.2Specimen NumberUnique identifier for specimen, as referenced by placer application, filler application, or bothSPM.4.1Specimen Type CodeSite-specific code for specimen typeSPM.4.2Specimen TypeName of specimen typeSPM.4.3Specimen Type Coding SystemCoding system used in Specimen Type Code fieldSPM.8.1Specimen Source Site CodeCode describing body site for specimen collectionSPM.8.2Specimen Source SiteName of body site for specimen collectionSPM.8.3Specimen Source Site Coding SystemCoding system used in Specimen Source Site Code fieldCoded ValuesPlease provide your Hospital/Clinic Codes in each of the tables below if different from the Standard Code listed for each description. Facility CodesPlease enter all facility codes that will be sent in MSH.4 and corresponding facility name (separate each facility code and facility name with a carriage return).Facility Code(s)Facility Name(s)Allergen Type CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesAnimal allergyAADrug allergyDAEnvironmental allergyEAFood allergyFAPollen allergyLAMiscellaneous allergyMAMiscellaneous contraindicationMCPlant allergyPAAllergen Severity CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesMildMIModerateMOSevereSVUnknownUObservations Result Status CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesRecord coming over is a correction and thus replaces a final resultCDeletes the OBX recordDFinal results; Can only be changed with a corrected result.FSpecimen in lab; results pendingINot asked; used to affirmatively document that the observation identified in the OBX was not sought when the universal service ID in OBR-4 implies that it would be sought.NOrder detail description only (no result)OPreliminary resultsPResults entered -- not verifiedRPartial results. Deprecated. Retained only for backward compatibility as of V2.6.SResults status change to final without retransmitting results already sent as 'preliminary.' E.g., radiology changes status from preliminary to finalUPost original as wrong, e.g., transmitted for wrong patientWResults cannot be obtained for this observationXAbnormal Flag CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesBelow absolute low-off instrument scale<Above absolute high-off instrument scale>Abnormal (applies to non-numeric results)AVery abnormal (applies to non-numeric units, analogous to panic limits for numeric units)AAAnti-complementary substances presentACBetter-use when direction not relevantBSignificant change downDDetectedDETAbove high normalHAbove upper panic limitsHHIntermediate. Indicates for microbiology susceptibilities only.IIndeterminateINDBelow low normalLBelow lower panic limitsLLModerately susceptible. Indicates for microbiology susceptibilities only.MSNormal (applies to non-numeric results)NNot DetectedNDNegativeNEGNon-reactiveNRPositivePOSQuality Control FailureQCFResistant. Indicates for microbiology susceptibilities only.RReactiveRRSusceptible. Indicates for microbiology susceptibilities only.SCytotoxic substance presentTOXSignificant change upUVery susceptible. Indicates for microbiology susceptibilities only.VSWorse-use when direction not relevantWWeakly reactiveWRDiagnosis Type CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesAdmittingAFinalFWorkingWDiagnosis Coding System CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesICD-9I9ICD-10I10Snomed Clinical TermsSCTDiagnosis PriorityStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesNot included in diagnosis ranking0The primary diagnosis1First other diagnosis 2Second other diagnosis3Present on Admission Indicator CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesYesYNoNExemptEUnknownUNot ApplicableWProcedure Coding System Type CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesCPTCPTICD-9I9ICD-10I10HCPCSHCPCSSnomed Clinical TermsSCTProblem Action CodeStandard DescriptionStandard CodeHospital/Clinic Code (if different from Standard)NotesAddADCorrectCODeleteDELinkLIUnchangeUCUnlinkUNUpdateUPPatient Class CodeStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesInpatientIOutpatientOEmergencyEObstetricsBPre-admitPRecurringRUnknownUNot ApplicableNAdmission Type CodeStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesElectiveCEmergencyEUrgentUAccidentALabor and DeliveryLNewbornNRoutineRAdmission Source CodeStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesPhysician referral1Clinic referral2HMO referral3Transfer from a hospital (different facility)4Transfer from a skilled nursing facility5Transfer from another health care facility6Emergency room7Court/law enforcement8Information not available9Transfer from one distinct unit of the hospital to another distinct unit of the hospital resulting in a separate claim to the payerDTransfer from ambulatory surgery centerETransfer from a hospice facilityFRaceStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesAmerican Indian or Alaska Native 1002-51002-5Asian 2028-92028-9Black or African American 2054-52054-5Native Hawaiian or Pacific Islander 2076-82076-8White2106-32106-3Other Race 2131-12131-1EthnicityStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesHispanic or LatinoHNot Hispanic or LatinoNUnknownUGenderStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesAmbiguousAFemaleFMaleMOtherOUnknownUPlan Type CodeStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesMedicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan12Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan13Medicare Secondary, No-fault Insurance including Auto is Primary14Medicare Secondary Worker's Compensation15Medicare Secondary Public Health Service (PHS) or Other Federal Agency16Medicare Secondary Black Lung41Medicare Secondary Veteran's Administration42Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)43Medicare Secondary, Other Liability Insurance is Primary47Auto Insurance PolicyAPCommercialC1Consolidated Omnibus Budget Reconciliation Act (COBRA)COMedicare Conditionally PrimaryCPDisabilityDDisability BenefitsDBExclusive Provider OrganizationEPFamily or FriendsFFGroup PolicyGPHealth Maintenance Organization (HMO)HMHealth Maintenance Organization (HMO) - Medicare RiskHNSpecial Low Income Medicare BeneficiaryHSIndemnityINIndividual PolicyIPLong Term CareLCLong Term PolicyLDLife InsuranceLILitigationLTMedicare Part AMAMedicare Part BMBMedicaidMCMedigap Part AMHMedigap Part BMIMedicare PrimaryMPOtherOTMedicare OtherOTHMProperty Insurance - PersonalPEPersonalPLPersonal Payment (Cash - No Insurance)PPPreferred Provider Organization (PPO)PRPoint of Service (POS)PSQualified Medicare BeneficiaryQMProperty Insurance - RealRPSupplemental PolicySPTax Equity Fiscal Responsibility Act (TEFRA)TFWorkers CompensationWCWrap Up PolicyWUDischarge Disposition CodeStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesUnknown/other00Discharged to home or self-care (routine discharge)01Discharged/transferred to another short-term general hospital for inpatient care02Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care03Discharged/transferred to a facility that provides custodial or supportive care04Discharged/transferred to a designated cancer center or children's hospital05Discharged/transferred to home under care of organized home health service organization in anticipation of covered skilled care06Left against medical advice or discontinued care07Admitted as an inpatient to this hospital09Expired20Discharged/transferred to court/law enforcement21Still patient or expected to return for outpatient services30Expired at home40Expired in a medical facility (e.g. hospital, SNF, ICF, or free standing hospice)41Expired - place unknown42Discharged/transferred to a federal health care facility43Hospice - home50Hospice - medical facility (certified) providing hospice level of care51Discharged/transferred to a hospital-based Medicare approved swing bed61Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital62Discharged/transferred to a Medicare certified long term care hospital (LTCH)63Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare64Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital65Discharged/transferred to a Critical Access Hospital (CAH)66Discharged/transferred to another type of health care institution not defined elsewhere in this code list70Marital Status CodeStandard DescriptionStandard CodeHospital/Clinic Code(if different from Standard)NotesSeparatedAUnmarriedBCommon lawCDivorcedDLegally separatedELiving togetherGInterlocutoryIMarriedMAnnulledNOtherODomestic partnerPRegistered domestic partnerRSingleSUnreportedTUnknownUWidowedW ................
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