Entities in the CPMC Clinical Data Repository
The Clinical Data Repository contains information about the care of patients at CPMC. Clinical Events form the
core of the medical record, documenting the major observations, treatments and other activities that occur as part
of a patient's care. Detail about clinical events (called "components") consists of an enormous variety
of structured data elements plus text reports dictated by care providers. The Repository also manages information
about people places and organizations involved in the health care process, as well as tracking insurance information.
Clinical Events
- LAB_EVENT
- The result of a laboratory procedure analyzing a specimen extracted from a patient, e.g. the level of sodium
in the blood.
- SERVICE_EVENT
- A diagnostic or therapeutic service (other than laboratory tests) performed on behalf of the patient, e.g.
a chest x-ray or administration of a medication.
- MANAGEMENT_EVENT
- General administration of a patient, e.g., admission to a bed, visit to a clinic, or assignment of a physician.
- ORDER_EVENT
- A request by a provider for a service to be peformed for a patient, e.g., a prescription for a course of medication.
- ASSESSMENT_EVENT
- Evaluation of a patient's condition, e.g., a diagnosis or a problem
- DECISION_EVENT
- A warning, suggestion, critique, or interpretation generated by the decision support system.
Detail about Clinical Events
- LAB_COMP
- A detail item of the result of a laboratory procedure, e.g. the value of a test, a comment, or an organism
that was cultured out.
- SERVICE_COMP
- A detail item of a service event, e.g., height in a physical exam, or a finding in a pathology report.
- SERVICE_TEXT
- A section of a report associated with a service event, e.g. the impression section of radiology report summarizing
the findings of an x-ray.
- MANAGEMENT_COMP
- A detail item of a management event, e.g. demographic items obtained at the time of admission.
- MANAGEMENT_TEXT
- A section of a report associated with a management event, e.g. the course in hospital of a discharge summary.
- ORDER_COMP
- A detail item of an order event, e.g., the route, dose, or frequency of a drug order.
- ASSESSMENT_COMP
- A detail item of an assessment event, e.g. the problems identified during an outpatient visit.
- ASSESSMENT_TEXT
- A report associated with an assessment event, e.g. comments associated with a medical problem.
- DECISION_COMP
- A detail item of a decision event.
- DECISION_LOG
- A record showing which users have seen which decisions made by medical logic modules.
- DECISION_TEXT
- Text associated with a decision event, e.g., comments made by a user in reponse to an alert.
People, Places, and Organizations
- PATIENT
- An inpatient or outpatient, with associated core demographic information.
- PATIENT_ALIAS
- An alternate name by which the patient is know, e.g. a maiden name.
- PROVIDER
- A health care professional who plays a role in patient care, e.g. a physician, nurse, or therapist.
- AFFILIATION
- A role played by a provider in an organization, e.g. being a member of a department or having admitting privileges
at a hospital.
- ASSOCIATION
- A relationship between one provider and another, e.g. being a chief resident in charge of another resident.
- LOCATION
- A physical location withing the institution, e.g. a patient room, emergency room, operating room or office.
- ORGANIZATION
- An organizational unit pertaining to health care, e.g. a hospital, department, or division.
Insurance
- COVERAGE
- The insurance policy used to cover a particular patient case.
- INSURANCE
- A insurance policy associated with a patient (at no particular time).
- PAYOR
- A third-party payor for health care.
- POLICY_HOLDER
- An individual holding a policy with a particular payor.
Stephen Johnson