Diagnosis

Indicates the record type. For this record it will always be “Diagnosis”.

Surrogate Key

Surrogate key to a patientCorresponds to a (Patient line in the same file set)’s ID value

Surrogate Key to an EncounterCorresponds to a (Encounter line in the same file set)’s ID value

Text based description of the diagnosis. This is primarily used for text based diagnosis entries. Since most diagnoses are codified, this field can be ignored.

Date diagnosis assigned

If Dx was rescinded. Usually blank

Surrogate Key to a Caregiver. The doctor of record that gave the diagnosis.Corresponds to a (Caregiver line in the same file set)’s ID value

code|name|namespace|family|ns desc. This would typically be an ICD9/10, but could be a Term that is defined by the source system. This field is preferred, but this or the ‘Description’ field must be populated.

code|name|namespace|family|ns desc. A description of the Diagnosis type. Example would be “Admitting” or “Primary” or “Secondary” or “Billing”

code|name|namespace|family|ns desc. For Example - V or Verified, F or Final, or leave blank

Part of Natural Key Identifier. Typically, the source’s or practice’s key Identifier for a patient *Natural Key for existing patient

Surrogate Key to a Record Authority.

Part of Natural Key Identifier. Typically the source’s or practice’s key Identifier for an encounter *Natural Key for existing encounter

Part of Natural Key Identifier. Typically, the source’s or practice’s key Identifier for a caregiver *Natural Key for existing caregiver

Surrogate Key to a Record Authority.

See Term List Format – List of terms

Audit data for when the record was inserted/created

Audit data for when the record was last modified

Code|Name. See Data Source Format - Source of the data