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EHR_EXTRACT: The top-level container of part or all of the health and adult social care record of a single subject of care, for communication between an EHR Provider system and an EHR Recipient.
FOLDER: The high level organisation within a health and adult social care record, dividing it into compartments relating to care provided for a single condition, by a clinical team or institution, or over a fixed time period such as an episode of care. Examples of FOLDER are Diabetes care, Schizophrenia, Cholecystectomy, Paediatrics, St Mungo’s Hospital, GP Folder, Episodes 2000-2001, Italy.
COMPOSITION: The set of information committed to one health and adult social care record as a result of a clinical encounter or a record documentation session. Examples of COMPOSITION are Progress note, Laboratory test result form, Radiology report, Referral letter, Clinic visit, Clinic letter, Discharge summary, Functional health assessment, Diabetes review.
SECTION: EHR data within a COMPOSITION that belongs under one care heading, usually reflecting the flow of information gathering during a care encounter, or structured for the benefit of future human readership. Examples of SECTION are Reason for encounter, Past history, Family History, Allergy information, Subjective symptoms, Objective findings, Analysis, Plan, Treatment, Diet, Posture, Abdominal examination, Retinal examination.
ENTRY: The information recorded in a health and adult social care record as a result of one clinical action, one observation, one clinical interpretation, or an intention. This is also known as a clinical statement. Examples of ENTRY are a symptom, an observation, one test result, a prescribed drug, an allergy reaction, a diagnosis, a differential diagnosis, a differential white cell count, blood pressure measurement.
CLUSTER: The means of organising nested multi-part data structures such as time series, list or tables. Examples of CLUSTER are Audiogram results, electro-encephalogram interpretation, weighted differential diagnoses.
ELEMENT: The leaf node of the health and adult social care record hierarchy, containing a single data value. Each ELEMENT contains data of a particular Data Type. Examples of ELEMENT are Systolic blood pressure, heart rate, drug name, symptom, body weight.
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