An accommodation is a service provided for a Person or other LivingSubject in which a place is provided for the subject to reside for a period of time. Commonly used to track the provision of ward, private and semi-private accommodations for a patient.

A unit of work, a grouper of work items as defined by the system performing that work. Typically some laboratory order fulfillers communicate references to accessions in their communications regarding laboratory orders. Often one or more specimens are related to an accession such that in some environments the accession number is taken as an identifier for a specimen (group).

A record of something that is being done, has been done, can be done, or is intended or requested to be done.

*Examples:*The kinds of acts that are common in health care are (1) a clinical observation, (2) an assessment of health condition (such as problems and diagnoses), (3) healthcare goals, (4) treatment services (such as medication, surgery, physical and psychological therapy), (5) assisting, monitoring or attending, (6) training and education services to patients and their next of kin, (7) and notary services (such as advanced directives or living will), (8) editing and maintaining documents, and many others.

Discussion and Rationale: Acts are the pivot of the RIM; all domain information and processes are represented primarily in Acts. Any profession or business, including healthcare, is primarily constituted of intentional and occasionally non-intentional actions, performed and recorded by responsible actors. An Act-instance is a record of such an action.

Acts connect to Entities in their Roles through Participations and connect to other Acts through ActRelationships. Participations are the authors, performers and other responsible parties as well as subjects and beneficiaries (which includes tools and material used in the performance of the act, which are also subjects). The moodCode distinguishes between Acts that are meant as factual records, vs. records of intended or ordered services, and the other modalities in which act can appear.

One of the Participations that all acts have (at least implicitly) is a primary author, who is responsible of the Act and who "owns" the act. Responsibility for the act means responsibility for what is being stated in the Act and as what it is stated. Ownership of the act is assumed in the sense of who may operationally modify the same act. Ownership and responsibility of the Act is not the same as ownership or responsibility of what the Act-object refers to in the real world. The same real world activity can be described by two people, each being the author of their Act, describing the same real world activity. Yet one can be a witness while the other can be a principal performer. The performer has responsibilities for the physical actions; the witness only has responsibility for making a true statement to the best of his or her ability. The two Act-instances may even disagree, but because each is properly attributed to its author, such disagreements can exist side by side and left to arbitration by a recipient of these Act-instances.

In this sense, an Act-instance represents a "statement" according to Rector and Nowlan (1991) [Foundations for an electronic medical record. Methods Inf Med. 30.] Rector and Nowlan have emphasized the importance of understanding the medical record not as a collection of facts, but "a faithful record of what clinicians have heard, seen, thought, and done." Rector and Nowlan go on saying that "the other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view." Indeed the Act class is this attributable statement, and the rules of updating acts (discussed in the state-transition model, see Act.statusCode) versus generating new Act-instances are designed according to this principle of permanent attributable statements.

Rector and Nolan focus on the electronic medical record as a collection of statements, while attributed statements, these are still mostly factual statements. However, the Act class goes beyond this limitation to attributed factual statements, representing what is known as "speech-acts" in linguistics and philosophy. The notion of speech-act includes that there is pragmatic meaning in language utterances, aside from just factual statements; and that these utterances interact with the real world to change the state of affairs, even directly cause physical activities to happen. For example, an order is a speech act that (provided it is issued adequately) will cause the ordered action to be physically performed. The speech act theory has culminated in the seminal work by Austin (1962) [How to do things with words. Oxford University Press].

An activity in the real world may progress from defined, through planned and ordered to executed, which is represented as the mood of the Act. Even though one might think of a single activity as progressing from planned to executed, this progression is reflected by multiple Act-instances, each having one and only one mood that will not change along the Act-instance life cycle. This is because the attribution and content of speech acts along this progression of an activity may be different, and it is often critical that a permanent and faithful record be maintained of this progression. The specification of orders or promises or plans must not be overwritten by the specification of what was actually done, so as to allow comparing actions with their earlier specifications. Act-instances that describe this progression of the same real world activity are linked through the ActRelationships (of the relationship category "sequel").

Act as statements or speech-acts are the only representation of real world facts or processes in the HL7 RIM. The truth about the real world is constructed through a combination (and arbitration) of such attributed statements only, and there is no class in the RIM whose objects represent "objective state of affairs" or "real processes" independent from attributed statements. As such, there is no distinction between an activity and its documentation. Every Act includes both to varying degrees. For example, a factual statement made about recent (but past) activities, authored (and signed) by the performer of such activities, is commonly known as a procedure report or original documentation (e.g., surgical procedure report, clinic note etc.). Conversely, a status update on an activity that is presently in progress, authored by the performer (or a close observer) is considered to capture that activity (and is later superceded by a full procedure report). However, both status update and procedure report are acts of the same kind, only distinguished by mood and state (see statusCode) and completeness of the information.

Description:

An acquisition exposure act describes the proximity (location and time) through which the participating entity was potentially exposed to a physical (including energy), chemical or biological agent from another entity. The acquisition exposure act is used in conjunction with transmission exposure acts as part of an analysis technique for contact tracing. Although an exposure can be decomposed into transmission and acquisition exposures, there is no requirement that all exposures be treated in this fashion.

Constraints: The Acquisition Exposure inherits the participation constraints that apply to Exposure with the following exception. The EXPSRC (exposure source) participation must never be associated with the Transmission Exposure either directly or via context conduction.

The Consent class represents informed consents and all similar medico-legal transactions between the patient (or his legal guardian) and the provider. Examples are informed consent for surgical procedures, informed consent for clinical trials, advanced beneficiary notice, against medical advice decline from service, release of information agreement, etc.

The details of consents vary. Often an institution has a number of different consent forms for various purposes, including reminding the physician about the topics to mention. Such forms also include patient education material. In electronic medical record communication, consents thus are information-generating acts on their own and need to be managed similar to medical activities. Thus, Consent is modeled as a special class of Act.

The "signatures" to the consent document are represented electronically through Participation instances to the consent object. Typically an informed consent has Participation.typeCode of "performer", the healthcare provider informing the patient, and "consenter", the patient or legal guardian. Some consent may associate a witness or a notary public (e.g., living wills, advanced directives). In consents where a healthcare provider is not required (e.g. living will), the performer may be the patient himself or a notary public.

Some consent has a minimum required delay between the consent and the service, so as to allow the patient to rethink his decisions. This minimum delay can be expressed in the act definition by the ActRelationship.pauseQuantity attribute that delays the service until the pause time has elapsed after the consent has been completed.

An Act where a container is registered either via an automated sensor, such as a barcode reader, or by manual receipt

An identified point during a clinical trial at which one or more actions are scheduled to be performed (definition mood), or are actually performed (event mood). The actions may or may not involve an encounter between the subject and a healthcare professional.

An action taken with respect to a subject Entity by a regulatory or authoritative body with supervisory capacity over that entity. The action is taken in response to behavior by the subject Entity that body finds to be undesirable.

Suspension, license restrictions, monetary fine, letter of reprimand, mandated training, mandated supervision, etc.Examples:

An interaction between entities that provides opportunity for transmission of a physical, chemical, or biological agent from an exposure source entity to an exposure target entity.

Examples: The following examples are provided to indicate what interactions are considered exposures rather than other types of Acts:

• A patient accidentally receives three times the recommended dose of their medication due to a dosing error.

  • This is a substance administration. Public health and/or safety authorities may also be interested in documenting this with an associated exposure.

• A patient accidentally is dispensed an incorrect medicine (e.g., clomiphene instead of clomipramine). They have taken several doses before the mistake is detected. They are therefore "exposed" to a medicine that there was no therapeutic indication for them to receive.

  • There are several substance administrations in this example. Public health and/or safety authorities may also be interested in documenting this with associated exposures.

• In a busy medical ward, a patient is receiving chemotherapy for a lymphoma. Unfortunately, the IV infusion bag containing the medicine splits, spraying cytotoxic medication over the patient being treated and the patient in the adjacent bed.

  • There are three substance administrations in this example. The first is the intended one (IV infusion) with its associated (implicit) exposure. There is an incident with an associated substance administration to the same patient involving the medication sprayed over the patient as well as an associated exposure. Additionally, the incident includes a substance administration involving the spraying of medication on the adjacent patient, also with an associated exposure.

• A patient who is a refugee from a war-torn African nation arrives in a busy inner city A&E department suffering from a cough with bloody sputum. Not understanding the registration and triage process, they sit in the waiting room for several hours before it is noticed that they have not booked in. As soon as they are being processed, it is suspected that they are suffering from TB. Vulnerable (immunosuppressed) patients who were sharing the waiting room with this patient may have been exposed to the tubercule bacillus, and must be traced for investigation.

  • This is an exposure (or possibly multiple exposures) in the waiting room involving the refugee and everyone else in the waiting room during the period. There might also be a number of known or presumed substance administrations (coughing) via several possible routes. The substance administrations are only hypotheses until confirmed by further testing.

• A patient who has received an elective total hip replacement procedure suffers a prolonged stay in hospital, due to contracting an MRSA infection in the surgical wound site after the surgery.

  • This is an exposure to MRSA. Although there was some sort of substance administration, it's possible the exact mechanism for introduction of the MRSA into the wound will not be identified.

• Routine maintenance of the X-ray machines at a local hospital reveals a serious breach of the shielding on one of the machines. Patients who have undergone investigations using that machine in the last month are likely to have been exposed to significantly higher doses of X-rays than was intended, and must be tracked for possible adverse effects.

  • There has been an exposure of each patient who used the machine in the past 30 days. Some patients may have had substance administrations.

• A new member of staff is employed in the laundry processing room of a small cottage hospital, and a misreading of the instructions for adding detergents results in fifty times the usual concentration of cleaning materials being added to a batch of hospital bedding. As a result, several patients have been exposed to very high levels of detergents still present in the "clean" bedding, and have experienced dermatological reactions to this.

  • There has been an incident with multiple exposures to several patients. Although there are substance administrations involving the application of the detergent to the skin of the patients, it is expected that the substance administrations would not be directly documented.

• Seven patients who are residents in a health care facility for the elderly mentally ill have developed respiratory problems. After several months of various tests having been performed and various medications prescribed to these patients, the problem is traced to their being "sensitive" to a new fungicide used in the wall plaster of the ward where these patients reside.

  • The patients have been continuously exposed to the fungicide. Although there have been continuous substance administrations (via breathing) this would not normally be documented as a substance administration.

• A patient with osteoarthritis of the knees is treated symptomatically using analgesia, paracetamol (acetaminophen) 1g up to four times a day for pain relief. His GP does not realize that the patient has, 20 years previously (while at college) had severe alcohol addiction problems, and now, although this is completely under control, his liver has suffered significantly, leaving him more sensitive to hepatic toxicity from paracetamol use. Later that year, the patient returns with a noticeable level of jaundice. Paracetamol is immediately withdrawn and alternative solutions for the knee pain are sought. The jaundice gradually subsides with conservative management, but referral to the gastroenterologist is required for advice and monitoring.

  • There is a substance administration with an associated exposure. The exposure component is based on the relative toxic level of the substance to a patient with a compromised liver function.

• A patient goes to their GP complaining of abdominal pain, having been discharged from the local hospital ten days' previously after an emergency appendectomy. The GP can find nothing particularly amiss, and presumes it is post operative surgical pain that will resolve. The patient returns a fortnight later, when the GP prescribes further analgesia, but does decide to request an outpatient surgical follow-up appointment. At this post-surgical outpatient review, the registrar decides to order an ultrasound, which, when performed three weeks later, shows a small faint inexplicable mass. A laparoscopy is then performed, as a day case procedure, and a piece of a surgical swab is removed from the patient's abdominal cavity. Thankfully, a full recovery then takes place.

  • This is a procedural sequelae. There may be an Incident recorded for this also.

• A patient is slightly late for a regular pacemaker battery check in the Cardiology department of the local hospital. They are hurrying down the second floor corridor. A sudden summer squall has recently passed over the area, and rain has come in through an open corridor window leaving a small puddle on the corridor floor. In their haste, the patient slips in the puddle and falls so badly that they have to be taken to the A&E department, where it is discovered on investigation they have slightly torn the cruciate ligament in their left knee.

  • This is not an exposure. There has been an incident.

Usage Notes: This class deals only with opportunity and not the outcome of the exposure; i.e. not all exposed parties will necessarily experience actual harm or benefit.

Exposure differs from Substance Administration by the absence of the participation of a performer in the act.

The following participations SHOULD be used with the following participations to distinguish the specific entities:

• The exposed entity participates via the "exposure target" (EXPTRGT) participation.

• An entity that has carried the agent transmitted in the exposure participates via the "exposure source" (EXSRC) participation. For example:

  • a person or animal who carried an infectious disease and interacts (EXSRC) with another person or animal (EXPTRGT) transmitting the disease agent;
  • a place or other environment (EXSRC) and a person or animal (EXPTRGT) who is exposed in the presence of this environment.

• When it is unknown whether a participating entity is the source of the agent (EXSRC) or the target of the transmission (EXPTRGT), the "exposure participant" (EXPART) is used.

• The physical (including energy), chemical or biological substance which is participating in the exposure uses the "exposure agent" (EXPAGNT) participation. There are at least three scenarios:

  1. the player of the Role that participates as EXPAGNT is the chemical or biological substance mixed or carried by the scoper-entity of the Role (e.g., ingredient role); or
  2. the player of the Role that participates as EXPAGNT is a mixture known to contain the chemical, radiological or biological substance of interest; or
  3. the player of the Role that participates as a EXPAGNT is known to carry the agent (i.e., the player is a fomite, vector, etc.).

The Exposure.statusCode attribute should be interpreted as the state of the Exposure business object (e.g., active, aborted, completed) and not the clinical status of the exposure (e.g., probable, confirmed). The clinical status of the exposure should be associated with the exposure via a subject observation.

Design Comment: The usage notes require a clear criterion for determining whether an act is an exposure or substance administration-deleterious potential, uncertainty of actual transmission, or otherwise. SBADM states that the criterion is the presence of a performer-but there are examples above that call this criterion into question (e.g., the first one, concerning a dosing error).

An event that occurred outside of the control of one or more of the parties involved. Includes the concept of an accident.

The act of transmitting information and understanding about a topic to a subject where the participation association must be SBJ.

Discussion: This act may be used to request that a patient or provider be informed about an Act, or to indicate that a person was informed about a particular act.

Working list collects a dynamic list of individual instances of Act via ActRelationship which reflects the need of an individual worker, team of workers, or an organization to manage lists of acts for many different clinical and administrative reasons. Examples of working lists include problem lists, goal lists, allergy lists, and to-do lists.

An officially or unofficially instituted program to track acts of a particular type or categorization.

An Act that of taking on whole or partial responsibility for, or attention to, safety and well-being of a subject of care.

Discussion: A care provision event may exist without any other care actions taking place. For example, when a patient is assigned to the care of a particular health professional.

In request (RQO) mood care provision communicates a referral, which is a request:

• from one party (linked as a participant of type author (AUT)),
• to another party (linked as a participant of type performer (PRF),
• to take responsibility for a scope specified by the code attribute,
• for an entity (linked as a participant of type subject (SBJ)).

The scope of the care for which responsibility is taken is identified by code attribute.

In event (EVN) mood care provision indicates the effective time interval of a specified scope of responsibility by a performer (PRF) or set of performers (PRF) for a subject (SBJ).

Examples:

1. Referral from GP to a specialist.
2. Assignment of a patient or group of patients to the case list of a health professional.
3. Assignment of inpatients to the care of particular nurses for a working shift.

Represents the act of maintaining information about the registration of its associated registered subject. The subject can be either an Act or a Role, and includes subjects such as lab exam definitions, drug protocol definitions, prescriptions, persons, patients, practitioners, and equipment.

The registration may have a unique identifier - separate from the unique identification of the subject - as well as a core set of related participations and act relationships that characterize the registration event and aid in the disposition of the subject information by a receiving system.

The act of examining and evaluating the subject, usually another act. For example, "This prescription needs to be reviewed in 2 months."

A procedure or treatment performed on a specimen to prepare it for analysis

The act of putting something away for safe keeping. The "something" may be physical object such as a specimen, or information, such as observations regarding a specimen.

Description:

A transmission exposure act describes the proximity (time and location) over which the participating source entity was capable of transmitting a physical (including energy), chemical or biological substance agent to another entity. The transmission exposure act is used in conjunction with acquisition exposure acts as part of an analysis technique for contact tracing. Although an exposure can be decomposed into transmission and acquisition exposures, there is no requirement that all exposures be treated in this fashion.

Constraints: The Transmission Exposure inherits the participation constraints that apply to Exposure with the following exception. The EXPTRGT (exposure target) participation must never be associated with the Transmission Exposure either directly or via context conduction.

Definition: The act of transferring information without the intent of imparting understanding about a topic to the subject that is the recipient or holder of the transferred information where the participation association must be RCV or HLD.

Transportation is the moving of a payload (people or material) from a location of origin to a destination location. Thus, any transport service has the three target instances of type payload, origin, and destination, besides the targets that are generally used for any service (i.e., performer, device, etc.)