Business Data Model Data Model

Entity

Entity Clinical Finding

Description

A finding that reports each individual test result or clinical observation.

Attributes
Clinical Finding Interpretation
Clinical Finding Type
Equipment Identifier Num
Finding Comparative Operator Symbol Name
Finding End Ts
Finding Identifier Num
Finding Lab Test Type
Finding Language
Finding Occurred Ts
Finding Repeat Qty
Finding Reported Ts
Finding Result Status
Finding Result Status Ts
Finding Subidentifier Num
Finding Unit
Finding Value Qty
Finding Value Txt
Finding Value Type
Finding Value Unit Of Measure
Finding Value Unit Type
Nature Of Abnormal Test
Observation Method
Organism Susceptibility
Priority Seq
Probability Num
Producing System Name
Reference Range Effective Date
Reference Range Txt
Relevant Clinical Information Txt
Result Handling Code
Test Set Num
Treatment Period Cnt
User Defined Access Check Txt

Relationship
Finding_Finding_FK
Finding_Clinical Order Detail_FK
Clinical Finding_Imaging Order_FK
Clinical Finding_Vaccination Order_FK
Clinical Finding_Pharmacy Order_FK
Clinical Finding_Document Header_FK
Clinical Finding_Patient_FK
Clinical Finding_Activity Procedure Observation (Clin Finding)_FK

Dependencies
NONE

Reverse Dependencies

Attribute Details

Clinical Finding Interpretation

Description	Describes a general interpretation of the clinical finding.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Clinical Finding Type

Description	A unique identifier used to identify the name and description for the clinical finding type in the common code table solution. For example: Cardiac Respiratory Pathology
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Equipment Identifier Num

Description	A number or combination of numbers and characters used to name the piece of equipment responsible for the production of the observation. It may be an organization's internal asset number or a manufacturer's serial number or some other reference number.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Comparative Operator Symbol Name

Description	Identifies the name of the finding comparative operator symbol for the clinical finding. For example: Greater than is Equals is = Less that is
Data Type	Standards - Data Domains.ddm/Data Domains/Name [VARCHAR(30)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding End Ts

Description	The date and time that a timed observation or test was completed. For example: Glucose Tolerance test is a series of blood glucose tests. Samples of blood are taken before the test begins and every 30 to 60 minutes after the person has drank a glucose drink. The last blood sample is considered the finding end timestamp.
Data Type	Standards - Data Domains.ddm/Data Domains/Timestamp [TIMESTAMP]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Identifier Num

Description	A unique identifier for the finding that has been generated by the application system for the submitting organization. It is an external identifier and has not been created internally.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Finding Lab Test Type

Description	Indicates the type of laboratory test that was performed for the clinical finding. For example: Potassium Level Calcium Level Full Blood Count
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Language

Description	Indicates the language used to describe the finding.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Occurred Ts

Description	The date and time when the clinical finding was observed or was performed.
Data Type	Standards - Data Domains.ddm/Data Domains/Timestamp [TIMESTAMP]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Repeat Qty

Description	The number of times an observation was performed for the clinical finding. For example: 3 Microscopic reviews of blood cultures to confirm sepsis 3 Urine dipsticks to confirm presence of a urinary tract infection
Data Type	Standards - Data Domains.ddm/Data Domains/Quantity Integer [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Reported Ts

Description	The date and time the clinical findings were officially recorded.
Data Type	Standards - Data Domains.ddm/Data Domains/Timestamp [TIMESTAMP]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Result Status

Description	Indicates the current condition of the clinical finding result. For example: Interim Final
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Finding Result Status Ts

Description	The date and time the clinical finding result status was recorded.
Data Type	Standards - Data Domains.ddm/Data Domains/Timestamp [TIMESTAMP]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Subidentifier Num

Description	A unique identifier for the clinical finding within a set of clinical findings for one clinical order.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Unit

Description	Identifies the Point of Care Location responsible for the clinical finding. For example: Hematology Radiology Microbiology
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Value Qty

Description	The numeric version of the Finding Value Text.
Data Type	Standards - Data Domains.ddm/Data Domains/Quantity Float [FLOAT(15)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Value Txt

Description	A description of the clinical finding result. The field may contain the exact scientific result or it may contain the normal/abnormal state of the test, i.e. quantitative or qualitative results. The field may contain a single or multi-part answer.
Data Type	Standards - Data Domains.ddm/Data Domains/Text Large [VARCHAR(1024)]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Finding Value Type

Description	Indicates the type of data that is contained within the clinical finding value. For example: Numerical Textual Images Recorded Signals
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	true
Is Derived	false
Is Surrogate Key	false

Finding Value Unit Of Measure

Description	The unit of measure in which the finding value quantity is expressed. For example: mmol= millimole kg = kilogram mcg = microgram iu= international units
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Finding Value Unit Type

Description	Indicates the unit of measure that is used in combination with Finding Value Type to describe the contents of the Finding Value Txt. International coding systems such as ISO may be used to define the list and description for all units of measure within a system. For example: mmol= millimole kg = kilogram mcg = microgram iu= international units
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Nature Of Abnormal Test

Description	An acronym or abbreviation that describes the characterization of the abnormal finding. For example: A race-based population A sex-based population An age-based population
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Observation Method

Description	Indicates the technique used to obtain the clinical finding. This is normally used to indicate that a different method than the standard method was used for the clinical finding. For example: Microscopic Titration Dipstick
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Organism Susceptibility

Description	Identifies a set of one or more observations about the resistance or vulnerability of an isolate (organism) to a drug, often an antibiotic. It is used by healthcare practitioners to prescribe the most appropriate medication for the patient's diagnosis. Susceptibilities are identified through microbiology testing. For example: The bacteria Clostridium Difficile is sensitive to the antibiotic clindamycin
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Priority Seq

Description	A number representing the relative order of importance for each clinical finding in a set.
Data Type	Standards - Data Domains.ddm/Data Domains/Sequence Number [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Probability Num

Description	A decimal number represented as text that indicates the likelihood that the clinical finding is true. The number is normally between 0 and 1.
Data Type	Standards - Data Domains.ddm/Data Domains/Name [VARCHAR(30)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Producing System Name

Description	Identifies the system responsible for producing the clinical finding. This may name an internal hospital system or an outside laboratory. In the United States the Medicare number for the producing system is the suggested identifier.
Data Type	Standards - Data Domains.ddm/Data Domains/Name Compound [VARCHAR(250)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Reference Range Effective Date

Description	The date upon which the reference range for a clinical finding is to be observed from.
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Reference Range Txt

Description	Reference ranges are values used to interpret clinical findings. The values include the upper and lower limits for a specific clinical finding. For example: Potassium has a reference range of 3.5 - 5.2 mmols/L , which means a potassium level above 5.2 mmols/l is considered high. If the finding quantifies a toxic substance, the upper limit identifies the toxic limit. If the finding measures a drug, the range represents the lower and upper therapeutic bounds.
Data Type	Standards - Data Domains.ddm/Data Domains/Description [VARCHAR(250)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Relevant Clinical Information Txt

Description	Additional descriptive information about the patient, specimen, or requested service. This type information can play a role in reporting clinical findings. For example: Rule out Sickle Cell Anaemia History of falls
Data Type	Standards - Data Domains.ddm/Data Domains/String [VARCHAR(255)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Result Handling Code

Description	Indicates how and under what conditions the outcome of a test or observation is to be treated. For example: Give to patient Notify provider when ready
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Test Set Num

Description	A number that identifies the test set that the specific clinical test is associated to.
Data Type	Standards - Data Domains.ddm/Data Domains/Identifier [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Treatment Period Cnt

Description	The number of times treatment is delivered to the patient for a specified period. For example: 6 radiotherapy sessions in a 3 month time frame 4 chemotherapy sessions in a 3 month time frame 8 physiotherapy sessions in a 3 month time frame
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

User Defined Access Check Txt

Description	A user-defined field that is used to record result-dependent codes for classifying the observation at the receiving system. For example: The sending service wants to send all the susceptibilities so that certain privileged users, such as Infectious Disease specialists, can review the results. Non-privileged users, however, can only see the preferred antimicrobials to which the organism was susceptible.
Data Type	Standards - Data Domains.ddm/Data Domains/String [VARCHAR(255)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Relationship Details

Finding_Finding_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Role Name	parent of
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Clinical Finding
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Finding_Clinical Order Detail_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Role Name	is finding for
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Clinical Order Item
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Clinical Finding_Imaging Order_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Role Name	is finding for
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Imaging Order
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Clinical Finding_Vaccination Order_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Role Name	is observation for
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Vaccination Order
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Clinical Finding_Pharmacy Order_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Role Name	is observation for
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Pharmacy Order
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Clinical Finding_Document Header_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Document
Parent Multiplicity	ZERO_TO_MANY
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Clinical Finding_Patient_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Patient
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Clinical Finding_Activity Procedure Observation (Clin Finding)_FK

Is Identifying Relationship	false
Child Table	Clinical Finding
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Activity Observation
Parent Multiplicity	ZERO_TO_MANY
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

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