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suggest including under SDOH. USCDI v3 includes Smoking Status under Health Status/Assessments
Active Ingredient: A chemical component of a Drug Product that supplies pharmacological activity or other direct effect in the Diagnosis, cure, mitigation, Treatment or prevention of Disease, or that affects the function of the human body.
Note: Defined based on Drug Product.Acute Public Health Event: Any Event that represents an immediate threat to human Health and requires prompt action (i.e., the implementation of control and/or mitigation measures to protect the Health of the public).Additional Address Description: Supplementary details provided alongside the Address for further context or clarification.
Note: Additional Address Description includes precise customer information to ensure that mail or packages are delivered to the proper Address.Address: Information used to identify a physical location.Address Line 2: A field for additional information to aid in the identification of an Address.
Note: Address Line 2 includes Address unit designators, such as apartment, suite, room or floor numbers.Adverse Drug Reaction: An unintended response that occurs after exposure to a Drug Product.
Note: Examples of adverse reactions include anaphylactic shock, hives and seizure.Adverse Event: An Event that is related to unintended effects on a Person receiving care. The unintended effects may require additional monitoring, Treatment or hospitalization, or may result in Death. Adverse Events can be reported by Health Care Providers, Persons receiving care or caregivers, or by Medical Product manufacturers.Alias: Alternative Names or labels that a Concept or Term may be known as in various contexts. Allergy/Intolerance: An immunological hypersensitivity (allergy) or a non-immunological adverse reaction (intolerance) to a Substance.
Note: Examples of allergies are reactions to bee venom, pollen and tree nuts. Examples of intolerances are reactions to gluten and lactose. Altitude: The absolute distance above sea level.Animal: For the purposes of the Pan-Canadian Health Data Content Framework, an Animal refers to any live, vertebrate Animal that directly or indirectly participates in the care of a Person.
Note: For the purposes of the Pan-Canadian Health Data Content Framework, a human is not considered an Animal.Appointment: A scheduled booking of an Encounter involving a Person receiving care, Health Care Provider and/or Related Person.
Note: An Appointment may result in 1 or more Encounters.Assessment: The evaluation of a Health Concern through a systematic analysis of the symptoms of a Person receiving care, the Patient Medical History, clinical findings and/or diagnostic test results, used by a Health Care Provider to form a clinical judgment or professional opinion about the Health of the Person receiving care.Attribute: A characteristic of an Entity that provides more specific information to distinguish it from other Entities. Author: An actor who creates or revises data.
Note: May be a Provider, a Patient, a Medical Device, an external medical record or another source. This attribution can inform Assessments about data quality, reliability and trustworthiness, or indicate where to look to determine the origin of the information.Birth: The complete expulsion or extraction of a Fetus from a Person, in which the Fetus breathes or shows another sign of life after being fully expelled or extracted, regardless of whether the umbilical cord has been cut or the placenta remains attached.
Note: Stillbirth is not included in this definition and is defined separately.Body Site: A specific anatomical region or structure on or within the human body.
Note: Body Site may include laterality.Business Context Model: This defines the scope of the Pan-Canadian Health Data Content Framework. The Business Context Model defines the people, Organizations and systems that influence and inform the content, the collaborators and those that govern and fund it. It also defines the consumers of the framework and the methods by which they will use it. Business Number: A unique, 9-digit number and the standard Identifier for businesses and legal entities registered with the Government of Canada.Business Rule: A specific statement that defines or constrains some aspects of business operation.
Note: These rules can cover governance, business processes, data management and regulation compliance.CA Core+: A set of FHIR profiles that enable common data exchange formats across domains, while also supporting domain-specific data exchange.
Note: The Canadian Core Data for Interoperability (CACDI) and CA Core+ work in tandem to facilitate interoperability and data exchange within the Canadian health care landscape. Canadian Clinical Drug Data Set: The drug interchange terminology used in Canada to uniquely identify and accurately describe drugs and Drug Products (and some Medical Devices) in a standardized format with defining properties.
Note: The Canadian Clinical Drug Data Set is freely used for digital health solutions and design applications.Canadian Core Data for Interoperability: A subset of the Pan-Canadian Health Data Content Framework that aims to define a standardized set of essential health Data Elements and associated Value Sets in the context of a common architecture to support interoperability and data exchange across the Canadian health care ecosystem.
Note: The development of the Canadian Core Data for Interoperability (CACDI) will follow an iterative design process and will expand over time. The CACDI and CA Core+ work in tandem to facilitate interoperability and data exchange within the Canadian health care landscape. Canadian Geographic Region: The grouping of Provinces and Territories established for the purpose of statistical reporting. The 6 geographical regions of Canada are as follows:
Atlantic
Quebec
Ontario
Prairies
British Columbia
Territories
Note: The Geographic Region definition fails to capture the rural and remote aspects of Canada's geography in health care.Canadian Postal Code: A 6-character alphanumeric Code defined and maintained by Canada Post Corporation for the purpose of sorting and delivering mail.
Note: Defined based on Forward Sortation Area (FSA) and Local Delivery Unit (LDU). The Canadian Postal Code is a 6-character uniformly structured, alphanumeric Code in the form “ANA NAN” where “A” is an alphabetic character and “N” is a numeric character. Care Team: All individuals who work, volunteer or learn together within the Organization to meet the needs of Persons receiving care, families and the community. As partners in care, Persons receiving care are recognized and treated as members of the Care Team, sharing in decision-making and accountability. The Care Team may also include leaders, management, staff, social and Health Care Professionals who hold privileges, contracted Providers, volunteers and students.
Note: The Care Team may be associated with a specific Encounter with 1 Person receiving care, a group of Persons receiving care or an Episode of Care and share in decision-making and accountability for the Person receiving care. The specific composition of teams depends on the type(s) of Service(s) provided and/or activity(ies) performed.Categorization: The grouping of data into meaningful categories based on common attributes or criteria.
Note: Categories do not need to be mutually exclusive.Census Agglomeration: An area formed by 1 or more adjacent municipalities centred on a population (known as the core). A Census Agglomeration (CA) must have a core population of at least 10,000, based on data from the previous Census of Population Program.
Note: To be included in the CA, other adjacent municipalities must have a high degree of integration with the core, as measured by commuting flows derived from data on place of work from the previous Census of Population Program.Census Agricultural Region: A geographic area within a Province or Territory formed for agricultural purposes.Census Consolidated Subdivision: A group of adjacent Census Subdivisions within the same Census Division.
Note: Generally, the smaller, more densely populated Census Subdivisions (e.g., towns, villages) are combined with the surrounding larger, more rural Census Subdivisions in order to create a geographic level between the Census Subdivision and the Census Division.Census Division: The group of neighbouring municipalities joined together for the purposes of regional planning and managing common Services (such as police or ambulance Services). These groupings are established under laws in effect in certain Provinces of Canada. Census Division (CD) is the general Term for provincially legislated areas (such as county, municipalité régionale de comté and regional district) or their equivalents.
Note: In other Provinces and the Territories where laws do not provide for such areas, Statistics Canada defines equivalent areas for statistical reporting purposes in cooperation with these Provinces and Territories. Census Divisions are intermediate geographic areas between the Province/Territory level and the municipality (Census Subdivision).Census Metropolitan Area: An area formed by 1 or more adjacent municipalities centred on a population (known as the core). A Census Metropolitan Area (CMA) must have a total population of at least 100,000, of which 50,000 or more must live in the core, based on adjusted data from the previous Census of Population Program.
Note: To be included in the CMA, other adjacent municipalities must have a high degree of integration with the core, as measured by commuting flows derived from data on place of work from the previous Census of Population Program.Census Metropolitan Influenced Zone: A Concept that geographically characterizes the areas of Canada outside Census Metropolitan Areas (CMAs) and Census Agglomerations (CAs).
Note: Census Subdivisions (CSDs) within Provinces that are outside CMAs and CAs are assigned to 1 of 4 categories according to the degree of influence (strong, moderate, weak or no influence) that the CMAs or CAs have on them. CSDs within the Territories that are outside CAs are assigned to a separate Census Metropolitan Influenced Zone (CMIZ) category.Census Subdivision: The general Term for municipalities (as determined by provincial/territorial legislation) or areas treated as municipal equivalents for statistical purposes (e.g., Indian reserves, Indian settlements, unorganized Territories).
Note: Municipal status is defined by laws in effect in each Province and Territory in Canada. The Term Indian is used to reflect the language used in legislation, such as the Indian Act, both historically and today. Census Tract: A small, relatively stable geographic area that usually has a population of less than 7,500 Persons, based on data from the previous Census of Population Program.
Note: Census Tracts are located in Census Metropolitan Areas (CMAs) and in Census Agglomerations (CAs) that had a core population of 50,000 or more in the previous census.Classification: The process of assigning data, Entities or Concepts to discrete, exhaustive and mutually exclusive classes based on rules or algorithms.
Note: Classification is based on 1 or more logical rules. The purpose of a Classification may vary. Clinical Note and Documentation: Narrative information and related reports recorded about a Person receiving care. This information includes progress notes, Patient Summary notes and other Clinical Note and Documentation formats.Code: The unique Identifier or expression used to represent a specific Coded Concept within a Code System.
Note: Codes serve as concise labels for standardized communication and data exchange. Code System: A structured collection of Coded Concepts, and their Formal definitions and assigned Codes. All Codes are unique within a Code System.
Note: Codes within a Code System are mutually exclusive. The structure of a Code System can organize Concepts in meaningful ways. Examples of a Code System include ICD-10-CA Classifications, SNOMED CT and Logical Observation Identifiers Names and Codes (LOINC).Codeable Concept: A Concept linked to a Value Set, where 1 or more Codes from the Value Set is used to represent the Concept.
Note: For example, one of the Values of the Codeable Concept "Allergy or Intolerance" may be "91935009," which represents the Coded Concept "Allergy to peanut" in the SNOMED CT Code System.Coded Concept: An idea represented by a unique Concept Identifier (Code) within a Code System or Value Set.Cohort: A defined collection of individuals who share common characteristics or experience over a specified period.
Note: A Cohort is often studied or monitored to identify health Events, or to analyze health outcomes, Interventions or trends.Concept: A distinct abstract idea that represents a category of real-world objects, Events, places or people.
Note: Examples of clinical Concepts include Provider, Immunization and Encounter. Examples of technical Concepts include "metadata," Value Set" and "Code."Conceptual Data Model: A high-level model that highlights the key real-world Concepts. This model provides more details than the Information Model but does not provide the detailed attributions that are in the Logical Data Models.Consultation: An Assessment provided following a written request from a referring physician or nurse practitioner who, based on their professional knowledge of the Person receiving care, seeks the opinion of a physician (the consultant physician) with relevant expertise. A Consultation is typically requested due to the complexity, seriousness or obscurity of the case, or at the request of the Person receiving care or their representative.
Note: In certain health care contexts, Referral and Consultation may be used interchangeably.
For the purposes of the Pan-Canadian Health Data Content Framework, a Consultation differs from a Referral in that it does not involve the temporary or partial transfer of care from one Provider to another.
Only Health Care Professionals may initiate a Consultation; while Persons receiving care may seek second opinions, they cannot formally initiate a Consultation themselves.
Continuous Episode of Care: A contiguous inpatient hospitalization or same-day surgery visit.
Note: Defined based on Episode of Care.Country: A geographic and/or political region of the world.Data Element: A distinct unit of information that represents a specific Attribute or characteristic in a Data Set.
Note: Examples include given Name, Person address type and Birth date.Data Set: A collection of Data Elements organized based on shared characteristics or intended purpose.Death: The irreversible cessation of all life-sustaining physiological functions of an individual.Description: A textual representation of a thing.Diagnosis: The process of identifying a Disease, Health Condition or injury based on the signs and symptoms experienced by a Person receiving care. A Diagnosis may be supported by a Patient Medical History, physical examination and diagnostic tests such as blood work, imaging or biopsies.Diagnostic Report: The findings and interpretation of diagnostic tests performed on Persons receiving care, groups of Persons receiving care, Products, Substances, Medical Devices, locations, or specimens derived from them.
Note: Includes clinical context such as requesting Provider information, as well as a mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic findings. The report may also include non-clinical context such as batch analysis and stability reporting of Products and Substances.Differential Diagnosis: A systematic method used to identify potential causes or conditions that may explain the symptoms or Health Concerns of a Person receiving care. Differential Diagnosis involves evaluating several possible diagnoses based on the Patient Medical History, physical examination, laboratory tests, imaging studies and other relevant information.
Note: The goal of a Differential Diagnosis is to narrow down the list of possible conditions and arrive at the most likely Diagnosis. Health Care Professionals use this process to rule in or rule out various Health Conditions and to determine the best course of Treatment or further diagnostic testing. Digital Identity: A piece of electronic information that uniquely identifies an individual or Organization.
Note: A Digital Identity can be stored on digital devices like smartphones and computers. Dimension: A parameter according to which data is classified or categorized.
Note: Defined based on Categorization and Classification.Disease: A Health Condition that affects the structure or function of part or all of the body or mind, often accompanied by specific signs and symptoms. It may be caused by internal or external factors, including pathogens, genetic conditions, lifestyle choices or environmental influences.Dissemination Area: A small, relatively stable geographic unit composed of 1 or more adjacent Dissemination Blocks with an average population of 400 to 700 Persons, based on data from the previous Census of Population Program.Dissemination Block: An area bounded on all sides by roads and/or boundaries of standard geographic areas.
Note: The Dissemination Block is the smallest geographic area for which population and dwelling counts are disseminated. Dissemination Blocks cover all of Canada.Document: A recorded piece of written, printed or electronic matter that provides information or evidence.Dose: The specific quantity of Substance of a Drug Product administered or prescribed at one time to achieve the desired therapeutic effect.
Note: The Dose may vary depending on factors such as the individual's age, weight and Health Condition. Dose Form: The physical formulation (e.g., tablet, capsule, solution, cream) of a Drug Product.
Note: Defined based on Dose.Dose Total Series: The recommended number of Doses of a vaccine required for immunity. This number may vary based on factors such as age, Health Conditions or previous Vaccination.
Note: Defined based on Immunization and Dose.Drug Identification Number: A unique, computer-generated 8-digit number assigned by Health Canada to a Drug Product in Canada.
Note: A Drug Identification Number (DIN) uniquely identifies Drug Products sold in a dosage form in Canada. It appears on the label of prescription and over-the-counter Drug Products that have been evaluated and authorized for sale in Canada. A DIN identifies the Drug Product's manufacturer, Name, Active Ingredient(s); strength(s), pharmaceutical form and Route of Administration. This number is assigned before a Drug Product is marketed in Canada.Drug Product: A Substance or mixture of Substances that can impart biological, physiological or psychological effects by exerting pharmacological, immunological or metabolic action.
Note: Drug Product includes both prescription and non-prescription drugs. These may be administered by a device but the Medical Device is not included in the definition of Drug Product.Drug Product Lot: A specific Drug Product batch that is identifiable by a unique Lot Number.
Note: Drug Product Lot is used to track and recall a Drug Product if necessary for the quality and efficiency of a particular batch. Drug Status: The life cycle state of availability of the Drug Product in the supply chain.Economic Region: A grouping of complete Census Divisions (CDs) created as a standard geographic unit for analysis of regional economic activity.
Note: There is 1 exception in Ontario.Effective Date: The first date when the information specified is valid.
Note: The default Value is metadata of when the record was created and requires no human input.Effective Date Time: The date and, if available, the time when the specified information first becomes valid.Encounter: A discrete, time-bound interaction between a Person receiving care (or group of Persons receiving care) and 1 or more Health Care Providers, occurring for the purpose of providing health care Services related to 1 or more Health Concerns.
Note: Encounters may occur in person or virtually and are typically coordinated or managed by a single responsible Health Care Organization. An Encounter may include Services delivered across multiple settings (e.g., an emergency department visit that leads to inpatient admission). While Organizations may define Encounters at varying levels of granularity, for analytical purposes, an Encounter should encompass the period from intake through to the conclusion of care activities associated with that visit, as managed by a single Organization.Entity: An encapsulation of data that is recognized by a domain expert as a representation of a discrete Concept.
Note: An Entity includes clinical Concepts related to health care such as "Immunization," as well as supporting Concepts such as "metadata," "code" and "business glossary."Entity Relationship: An association between Entities. It may be depicted in a data model by a line with each end showing the cardinality of the related Entities, which represents their allowed degrees of interaction (e.g., zero to many).
Note: Entity Relationships can represent hierarchies, including parent–children relationships.Episode of Care: All health care Encounters related to the Treatment of a specific Health Concern or set of concerns for a Person receiving care. An Episode of Care may involve past, current and future care provided across different Organizations.
Note: Each Episode of Care relates to a specific Person receiving care and may include multiple Encounters, potentially spanning different Organizations over a period of time. An Episode of Care does not have a defined end date.Essential for Exchange: An Attribute that must be exchanged, meaning it must be sent and received between systems implementing the Data Content Framework to ensure interoperability.
Note: Every vendor of an interoperable system implementing the framework is expected to demonstrate the ability to collect, send and receive each Attribute Essential for Exchange (generally through the relevant FHIR profile).Ethnicity: A multi-dimensional Concept that reflects a Person's sense of belonging to a cultural or social group. It relates to shared characteristics such as language, religion, geographic origin, nationality, cultural traditions, ancestry and migration history, among others.Event: An occurrence that has taken place, is currently happening or may occur in the future.
Note: Event is a broad definition that encompasses many subtypes of Events such as health Events, legal Events and environmental Events. Excipient: An inactive chemical component of a Drug Product that serves various purposes, such as ensuring stability, aiding in the delivery of the Active Ingredient and improving the appearance of the medication.
Note: Defined based on Drug Product. An Excipient does not produce health benefits for Persons receiving care.Expiry Date: The first date when the information specified is valid.
Note: The default Value is metadata of when the record is marked as inactive.Expiry Date Time: The date and, if available, the time when the specified information is last valid. Family History: A collection of Health Conditions and illnesses that affects or has affected the biological relatives of a Person receiving care.
Note: Family History can help identify genetic risks and predispositions associated with Diseases.Fast Healthcare Interoperability Resources: A standard for health care data exchange, published by HL7.Federal Electoral District: A geographic area represented by a member of Parliament in the House of Commons in Canada.
Note: Each Federal Electoral District (FED) is part of a single Province or Territory.Fetus: An unborn offspring developing inside the uterus (womb) of a human or other mammal. In humans, the fetal period begins at 9 weeks after fertilization and continues until Birth.
Note: In Canada, a Fetus does not have legal rights until it is born, at which point it is recognized as a baby under the law and global human rights standards.First Nations, Inuit and Métis Identity: A person’s self-identification as First Nations (registered member of a First Nations community as defined by the Indian Act), Inuk/Inuit (enrolled under or a beneficiary of an Inuit land claims agreement) or Métis (registered member of a Métis organization or Settlement).Formal: Refers to a structured, professional and official manner of operation that adheres to established rules, Protocols or conventions.
Note: Formal operations are typically more structured and longer-lasting than Informal ones. These operations include contractual agreements, defined responsibilities and Formal payment structures.Forward Sortation Area: The geographic area determined by the first 3 characters of the Canadian Postal Code, designating a postal delivery area within Canada.
Note: Each Forward Sortation Area (FSA) is part of a single Province or Territory.Gender Identity: An individual’s personal experience of being a woman, man or nonbinary, or how the Person prefers to self-describe.
Note: People may identify with more than one Gender Identity or use different Gender Identities in different settings.Gender Used: The gender that a Person wishes to have recorded on legal Documents or for the purposes of interactions with official agencies (e.g., driver’s licence).Geography Boundary: The abstract line(s) or physical feature(s) that separate one place or area from another.Health: An Attribute of individuals, communities and societies, and a fundamental resource for daily living. Health is shaped by a wide range of determinants, including genetics, individual behaviours (such as diet and physical inactivity), social and environmental exposures (such as early childhood experiences), education, employment and, most fundamentally, social and economic position.
Note: Health can be measured in many ways, such as by the presence or absence of Disease or through more qualitative understandings of personal or community assets and capabilities. Different individuals and cultures may perceive Health differently. For example, Indigenous Peoples' Concepts of Health and Well-Being are holistic, encompassing spiritual, environmental, cultural and social Dimensions in addition to physical and mental Health. Health is viewed as both an individual and collective right, strongly influenced by community, land and the natural environment. Indigenous Peoples’ approaches to Health emphasize balance among spirituality, traditional medicine, biodiversity and the interconnectedness of all that exists. These perspectives lead to an understanding of humanity that differs significantly from that of non-Indigenous society.Health Care Organization: A Formal group of individuals in an operational structure that delivers health care good(s) and Service(s).
Note: Health Care Organization includes a wide range of entities, from corporations to community groups. This encompasses public, private, non-profit and voluntary-sector Organizations.Health Care Professional: A Person who is contracted to provide a Health Care Service to a Person receiving care.Health Care Provider: An individual in a Formal role who has delivered, is delivering or may deliver health care–related goods and Services.
Note: Includes Health Care Professionals, personal support workers, volunteers, Elders and Knowledge Keepers associated with an Organization. This definition excludes Informal Caregivers such as neighbours and family members.Health Care Service: A Service provided by a Health Care Professional, or by an individual working under their supervision, that relates to the Diagnosis, prevention or Treatment of Disease or impairment in humans, or to the Assessment or care of human Health.Health Care Service Event: An act performed, being performed or planned by a Health Care Professional with the intent of directly or indirectly improving the Health of an individual or population.
Note: An act performed by an Informal Caregiver is not considered a Health Care Service Event (e.g., a parent administering a Dose to a child).Health Concern: Any health-related condition, situation or problem affecting a Person's physical, mental, cognitive or behavioural Health that may be documented during an Encounter.
Note: A Health Concern may involve issues reported by or on behalf of the Person receiving care, even if no Formal Diagnosis has been made (e.g., back pain, nausea).Health Concern Evidence: A manifestation or a symptom that led to the reporting of a Health Concern.Health Condition: A health problem or alteration in an individual that may cause distress, interfere with daily activities or result in contact with health Services. A Health Condition may be a Disease (acute or chronic), disorder, injury or trauma, or it may reflect other health-related states such as pregnancy, aging, stress, a congenital anomaly or a genetic predisposition that may lead to Death.Health Event: An occurrence or incident that relates to a Person's Health, Well-Being or health care.Health Function: The general Health Status and functional abilities of a population associated with the consequences of Diseases, disorders, injuries and other Health Conditions. Health Functions include body functions and structures (impairments), activities (activity limitations), participation (restrictions in participation) and life expectancy. Health Region: A geographic area defined by provincial and territorial governments and represents administrative bodies or areas of interest to health authorities.
Note: Health Regions include regions under the jurisdiction or responsibility of provincial and territorial governments or federal, provincial or territorial administrative bodies. Health regions, being provincial administrative areas, are subject to change. For complete Canadian coverage, each of the Territories, as well as the Province of Prince Edward Island, represents a single Health Region.Health Status: A multidimensional Concept that reflects a Person's overall Health, measured using various indicators and methods. Health Status can be assessed through standardized examinations, medical records or self-reported information.
Note: Includes factors such as Disease incidence and prevalence; physical, cognitive, emotional and social functioning; and disability.Hospital: An institution that provides medical, surgical or other types of care for people requiring diagnostic and/or therapeutic management of a Health Concern. A Hospital may offer both Diagnosis and Treatment, ranging from general care to specialized Services for specific Health Conditions or age groups.
Note: Can offer a wide range of Services and may be further categorized based on their specialization. Some Hospitals may also play a role in research and education.Identifier: A sequence of characters and/or numbers used to uniquely represent something within a specific context.
Note: A Code is a unique Identifier in a Code System. Examples include health care Identifiers, personal Identifiers and financial Identifiers.Immunization: The process by which a Person develops resistance to a Disease through exposure to an antigen. This process includes active Immunization, which can be acquired by Vaccination, and passive Immunization, which can be acquired through exposure.
Note: A Person receiving care may have an Immunization record summarizing all Diseases to which they are immune. While the Terms Immunization and Vaccination are not clinically identical, for the purposes of the Pan-Canadian Health Data Content Framework, Immunization includes both Immunizations and Vaccinations.Immunization Reaction: A reaction associated with an Immunization.
Note: Defined based on Immunization.Income Decile: A distribution measure of the population according to their income, divided into 10 equal groups, each representing 10% of the population. Income Quintile: A distribution measure of the population according to their income, divided into 5 equal groups, each representing 20% of the population. Informal: Refers to a casual or less structured style of operation, often in a non-professional setting.
Note: Informal operations are typically more flexible and temporary compared with Formal ones. These operations include arrangements without contractual agreements or Formal payment and are usually based on a pre-existing relationship between the individuals (e.g., family, friends).Informal Caregiver: An unregistered individual who offers support, assistance or care to another individual who may be unable to fully care for themselves due to illness, disability, aging or other challenges.
Note: Examples include family members, friends and neighbours.Information Model: A high-level model that highlights the key real-world Concepts important to understand a Person's Health and how they relate.Instruction: Information provided to a Person about an action to be taken.
Note: For example, details provided for medication dosage, Route of Administration, timing and other related information during Medication Dispensation.Integrated Care Plan: A coordinated plan outlining how 1 or more Health Care Providers intend to deliver care to a particular Person, group or community over a period of time. The plan may be limited to care for a specific Health Condition or set of conditions.
Note: An Integrated Care Plan considers the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of a Person receiving care. Integrated Care Plans provide guidance to caregivers so they can effectively support and respond to the individual needs of Persons receiving care.Intervention: An action or series of actions performed for, with or on behalf of a Person or population whose purpose is to observe, monitor, assess, improve, maintain, promote or modify Health, functioning or Health Conditions.
Note: Examples include an education program, an operation and a community health initiative.Latitude: The location of a point on the earth's surface, stated as an angular measurement in degrees, minutes and seconds north or south of the equator.
Local Delivery Unit: The last 3 characters of a Canadian Postal Code (numeric-alpha-numeric). This identifies the smallest delivery unit in a Forward Sortation Area.
Note: Local Delivery Unit is the last 3 characters of a Canadian Postal Code.Location (Geographical Information): A specific geographic position or site.Location Purpose: The rationale for providing information about the physical geographical coordinates of where a Party resides.
Note: Examples include business location, mailing location and billing location.Logical Data Model: A model that describes Entities, their Attributes, the acceptable Values for those Attributes and the relationships between the Entities.Longitude: The location of a point on the earth's surface, stated as an angular measurement in degrees, minutes and seconds east or west of the Greenwich prime meridian.Lot Number: A unique combination of letters, figures or both assigned to a specific group of Drug Products at the time of production that can be used to track its manufacturing, processing, packaging, holding and distributing history.
Note: Defined based on Drug Product Lot. Manufactured Drug Product: A brand-specific drug that is or, within the lifetime of the Canadian Clinical Drug Data Set (CCDD), has been available for prescribing and dispensing in Canada.
Note: An example is ACT AMLODIPINE (amlodipine [amlodipine besylate] 2.5 mg oral tablets) ACTAVIS PHARMA COMPANY.Medical Device: A manufactured instrument, apparatus, machine, software, implant or similar item that is intended for use in the monitoring, Diagnosis, prevention, mitigation or alleviation of a Health Condition or injury.Medication Administration: The process by which medication is given to a Person.
Note: Information regarding the Route of Administration, Dose and schedule may be documented.Medication Dispensation: The preparation and fulfillment of a medication Order by a pharmacist or other authorized Health Care Provider.
Note: The dispensing Provider(s) will review the pharmaceutical and therapeutic suitability of the medication and explain the administration Instruction to the Person receiving care.Medication Incident: A preventable Event that may cause or lead to harm to the Person receiving care while the medication is under the control of the Health Care Provider, the Person receiving care or the consumer.
Note: Examples include errors of administration and omission.Medication Request: An Order for a medication or Medical Device made by an authorized Health Care Provider. A Medication Request typically includes the medication Name, dosage, frequency and number of refills.Medication Statement: A summary record of all the medication(s) a Person is taking or could be taking.
Note: The Medication Statement lists any medication that could induce drug interactions or have an impact on the Health of a Person receiving care such as prescription medications, non-prescription medications, and natural health Products.Name: A word or combination of words by which a person, place or thing is referred to.
Note: Examples include Party Group name, Organization name and Person name.Non-Proprietary Therapeutic Drug Product: A brand-independent and clinically-oriented representation of a manufactured (therapeutic) Product.
Note: A Non-Proprietary Therapeutic Drug Product is characterized by the strength of its Active Ingredient(s), the dosage form and Unit of Presentation. An example includes amlodipine (amlodipine besylate) 2.5 mg oral tablet.Observation: A measurement or basic finding recorded about a Person receiving care, Medical Device or other subject, typically used to capture clinical or other relevant information.
Note: A central Concept in health care used to support Diagnosis, monitor progress, determine baselines and patterns, and capture demographic or clinical characteristics. Observations may include Medical Device measurements, laboratory atomic results, Vital Signs, height, smoking status and narrative comments.Order: A direction given by a Regulated Health Care Professional with legislated authority to request a Procedure, diagnostic test, medication or other clinical activity.
Note: Can apply to an individual Person receiving care through a direct Order, or to a group of Persons receiving care through a directive. Organization: A Formal collection of individuals in an operational structure formed to achieve a common purpose.
Note: Organization includes a wide range of entities, from corporations to community groups. Organizations may encompass public, private, non-profit and voluntary-sector Organizations.Participant: A Person who is taking part, has been taking part or will take part in a particular Event.Party: An individual or group of individuals with defined roles and common properties.
Note: An Organization is considered a Party.Party Group: A collective of individuals, Organizations or other Party Groups with shared characteristic(s) or purpose(s).
Note: Party Group includes both self-identified groups such as families and groups organized for analytical purposes such as Cohorts (e.g., diabetes management cohort).Party Group Criteria Text: The condition(s) used to define a Party Group.
Note: Defined based on Party Group. Examples include demographic information (e.g., age), geographic location and organizational role. Party Group Member: An individual or Organization in a specific Party Role, recognized as belonging to a Party Group at a given time.
Note: Certain Party Groups such as Virtual Health Networks have defined members, whereas other groups such as Cohorts do not. A Party (e.g., 1 Person) can be a member of a Party Group (e.g., Hospital Organization) in 1 or more of its roles (e.g., Patient, Provider).Party Group Name: The Name by which a Party Group is known to its members and to parties that interact with it.
Note: Defined based on Party Group and Name. Examples include Alcoholics Anonymous, Mississauga Cancer Survivors Support Group and Groupe de prévention de suicide de Rimouski. Party Group Purpose Text: The rationale for the formation of a specific Party Group.
Note: Examples include studying the effectiveness of heart Disease Treatment (Cohort purpose), alcohol recovery (Peer Support Group purpose) and health Service proximity (Virtual Health Network purpose). Party Group Type: A Code that designates the class of a Party Group.
Note: Defined based on Party Group and Classification.Party Role: A Party fulfilling a specific function related to the Canadian health care system.
Party Role Location: A specific geographically determined locale of a Party Role (e.g., of a Patient, of a Provider).
Note: Defined based on Party.Party Role Relationship: A pair of associated Party Roles related to the Canadian health care system. Party Role Relationship Type: A class of relationships that a Party Role can participate in.
Note: Examples include "is sister of," "is managed by" or "employee of." Defined based on Party Group and Classification.Party Role Type: A class of roles that Parties can fulfill.
Note: Examples of Person Role Type are Patient and Provider. Examples of Organization Role Type are Primary Care Organization and Identifier Issuing Organization.
Defined based on Party Group and Classification.Party Type: A class of Party as a Person, Organization or Party Group.Patient: A Person who has received, currently receives or is waiting to receive health care goods and Services from a Provider or Organization.
Note: Persons receiving care can be co-producers of their Health and are active Participants in their care. Depending on the health setting or context, Persons receiving care may be referred to as Patients, clients, residents or community members.Patient Encounter: An Encounter for 1 Person receiving care, either alone or in a group, to receive Health Care Service(s) from 1 or more Health Care Providers.
Note: Defined based on Encounter. Patient Encounter is an Encounter applied to a single Person receiving care. During a group Encounter (e.g., couples therapy session), a separate Patient Encounter is made for each individual.Patient Medical History: A record of health and socio-economic factors that affect or have affected the Health of a Person receiving care over time.
Note: Includes clinical findings, surgical history, Family History and genetic information. Patient Medical History may also include health habits such as exercise routines and an individual's overall sense of mental, physical and social Well-Being. Patient Summary: A standardized set of core clinical and socio-demographic data that captures the most important health and care information needed to support safe and secure health care.
Note: This summarized version of clinical data for a Person receiving care can give Health Care Professionals the essential information they need to provide care in unexpected or unscheduled situations (e.g., emergency, accident). This summary is mainly intended to support unscheduled care but can also be used in planned care scenarios (e.g., when Persons receiving care move across borders or organizational care pathways), and may serve as a central reference point within health records.Peer Support Group: A collection of individuals who share a common experience, condition or challenge, and come together to provide mutual support, encouragement and understanding to one another.Periprocedure Event: An Event associated with a health care Procedure that deviates from the expected or desired course and may cause, or be associated with, a suboptimal or changed outcome.Person: An individual human.
Note: Demographic, administrative and/or health information about a Person may be collected and maintained. A Person may be in the role of a Patient, a caregiver, a Provider or a relative of a Patient.Person Information: The administrative and socio-demographic information about a person.
Note: May include Name, sex at Birth, contact information and Address. This category is broader than personally identifiable information.Person Pronoun: A word used to refer to a Person instead of their Name, a noun or a noun phrase. Gender pronouns are third-person pronouns that may reflect a Person’s Gender Identity (e.g., he, she, they) and may be part of their gender expression.Person-Centred Care: An approach to care that prioritizes the perspectives of individuals, families and communities, recognizing them as active Participants and not just beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. This approach requires that people have the education and support they need to make decisions and participate in their own care. It is organized around the health needs and expectations of people, rather than Diseases.Population Health: The Health of a group of people, which can be influenced by social, economic and physical environments; personal health practices; individual capacity and coping skills; human biology; early childhood development; and Health Care Services. Population Health can be measured using Health Status indicators.
Note: The Population Health approach aims to improve the Health of the entire population and reduce health inequalities among population groups.
Population Health focuses on understanding why some groups are healthier than others, while Public Health refers to the organized effort to keep people healthy and prolong life. Preventive Care: Care focused on preventing health problems before they occur. Preventive Care involves identifying potential issues before symptoms or complications develop, when the chances of recovery are greatest. This approach supports overall Health.Primary Care Organization: A Health Care Organization that may be a first point of contact with the health system for non-emergency care for individuals, families and communities. It provides Services that bring Health Care Services as close as possible to where people live and work. These Services may include Diagnosis and Treatment, Referrals to specialized care, Population Health initiatives, Health Promotion, Preventive Care, community-based care and chronic Disease management.Primary Care Provider: A Health Care Professional who delivers Health Care Services such as Health Promotion, illness and injury prevention, and the Diagnosis and Treatment of illness and injury. For Persons receiving care, the Primary Care Provider is often the first point of contact with the health care system and serves as a central coordinator of care.
Note: May include residents in training to be general practitioners, family physicians, nurse practitioners and physician assistants. Primary Care Providers take responsibility for overarching and proactive medical care, ensuring follow-up and facilitating transitions of care or Referrals when needed.Procedure: A set of actions involving the manipulation of tissue — such as skin, mucosa or deeper structures — through surgical or non-surgical means, performed for preventive, therapeutic and/or diagnostic purposes.Procedure Tolerance: The response of a Person receiving care to a Procedure performed on them, typically documented with statements such as "tolerated well" or "no immediate complications."
Note: May indicate whether complications have occurred.Product: A tangible good, intangible Service or any combination thereof.
Note: This may include health Products, digital Products or commercial Products.Protocol: A set of guidelines and standards on how particular processes and actions should be carried out.
Note: Clinical Protocols are typically informed by a systematic review of evidence and include recommendations to optimize health care.Provider: An individual who delivers, has delivered or may deliver health care–related goods or Services.
Note: Includes Health Care Professionals, personal support workers, volunteers, Elders and Knowledge Keepers. Province or Territory: The Name associated with geographic boundaries in Canada, as well as the major political units of Canada.Pseudo Drug Identification Number: An 8-digit number assigned by a drug program in cases where a benefit has not been assigned a Drug Identification Number (DIN) by Health Canada.
Note: This is to typically identify non-drug benefits (e.g., diabetic supplies) and is sometimes used to differentiate benefits based on package size or covered indication (e.g., methadone for addiction versus pain control).Public Health: The organized effort to keep populations healthy and prevent injury, illness and premature Death. It involves a combination of programs, Services and policies that protect and promote the Health of all individuals.
Note: Public Health is a sector of the health system whose core functions include health surveillance, Health Promotion, and emergency preparedness and response.
Population Health focuses on understanding why some groups are healthier than others, while Public Health refers to the organized effort to keep people healthy and prolong life.Racialized Group: A social construct used to judge and categorize people based on perceived differences in physical appearance in ways that create and maintain power differentials within social hierarchies.
Note: There is no scientifically supported biological basis for discrete racial groups.Reaction Manifestation: A symptom or sign associated with an allergy or intolerance reaction. Reason: An explanation or justification for an action.
Note: Reasons for clinical actions, such as Procedures or Medication Requests, are usually related to the Health Concerns of the Person receiving care. For example, the Reason for a Medication Request may be the signs, symptoms or Health Conditions that prompted it.Recommended for Exchange: An Attribute recommended to be available for exchange, meaning it should be sent and received between interoperable systems implementing the Data Content Framework.Recorded Sex or Gender: The documented sex or gender of an individual used for clinical, official or legal purposes where only 1 data field for sex and gender is available, and where it is the Value found in the local system and/or historical documentation.Referral: A request by one Health Care Provider to another for a Health Care Service to be provided to a Person receiving care.
Note: In certain health care contexts, Referral and Consultation may be used interchangeably.
For the purposes of the Pan-Canadian Health Data Content Framework, a Consultation differs from a Referral in that a Referral may involve the temporary or partial transfer of care from one Provider to another.
While Referrals are often initiated by Health Care Professionals, self-Referrals (by Persons receiving care or Informal Caregivers) are also common in some care settings.Regulated: To be governed or controlled by provincial, territorial and sometimes federal law.
Note: Governments may designate a professional or regulatory body to monitor the membership and scope of practice for a Regulated occupation. Through these laws, Regulated occupations are granted the ability to perform controlled acts such as prescription and surgery.Related Health Concern: A Health Concern associated with some other Health Concern of interest for the same Person receiving care.Related Person: A Person involved in the Health or care of a Person receiving care who is not the primary recipient of Health Care Services.
Note: Related Persons typically have a personal or non-health care–specific professional relationship with the Person receiving care. The Related Person resource is primarily used for information attribution, as these individuals are often sources of information about the Person receiving care. For contact purposes, use the Contact element for the Patient. Some individuals may serve as both a Contact and a Related Person for the Patient.Research Study: A systematic investigation, such as research development, testing or evaluation, designed to develop or contribute to generalizable knowledge.Route of Administration: The path by which a Substance enters or comes into contact with the body (e.g., oral, intramuscular, mucosal).Semantic: Relating to meaning, usually the meaning of words, phrases or symbols.
Note: Semantic interoperability provides a common underlying model and codification of data, including the use of Data Elements with standardized definitions from publicly available Value Sets and coding vocabularies. This approach supports shared understanding and consistent meaning across systems and users.Service: An intangible action performed by an individual, Organization or system to address a specific need or problem at a particular point in time. This action may include health care, technology or educational Services.
Note: In the context of the Pan-Canadian Health Data Content Framework, Services help enact Interventions.Service Language: The preferred language of Service for an individual, a group of individuals or an Organization.Sex Parameter for Clinical Use: A parameter that provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status or obstetric history.
Note: Should be documented only when clinically required, and in a manner or location that ensures it is visible only to those who need the information. This parameter is intended to support clinical decision-making and indicates that Treatment or diagnostic tests should consider best practices associated with the relevant reference population.Sexual Orientation: How a Person describes their sexuality or who they are romantically, emotionally or physically attracted to.Social Determinants of Health: The non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.
Note: Social Determinants of Health forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.Social Determinants of Health Assessment: A detailed evaluation of the social and environmental factors that influence an individual's Health and Well-Being. This Assessment may include factors such as education level, housing stability and access to Health Care Services.Specialist: A Health Care Professional who has received additional training and may be certified or licensed to practise in a specific area of medicine.
Note: Specialists focus on a specific area of medicine or a group of Persons receiving care to diagnose, manage, prevent or treat certain symptoms and Health Conditions.Specialty: A distinct branch of medical or clinical practice defined by the type of Patient, the Diseases addressed, the skills required or the specific approach taken by the Health Care Professional. For example, cardiology is a Specialty focused on the Diagnosis and Treatment of the heart and related Diseases.
Note: Not a specialization, but rather a defined area of specialized practice. For example, a cardiologist is a Specialist, whereas cardiology is a Specialty. Any Health Care Professional may have a Specialty.Standardized Assessment: A test administered and scored according to prescribed Procedures followed by all professionals who use it. Results may be interpreted using a structured approach that compares the results of the Person receiving care to a representative sample of people with similar characteristics (e.g., same-age peers).Statistical Area Classification: The grouping of Census Subdivisions (CSDs) according to whether they are a component of a Census Metropolitan Area (CMA), a Census Agglomeration (CA) or a Census Metropolitan Influenced Zone (MIZ).
Note: CSDs within Provinces that are outside CMAs and CAs are assigned to 1 of 4 categories according to the degree of influence (strong, moderate, weak or no influence) that the CMAs or CAs have on them. CSDs within the Territories that are outside CAs are assigned to a separate category.
The SAC is a variant of the Standard Geographical Classification (SGC). CSDs form the lowest level of the Classification variant. The next level consists of CMAs, CAs and MIZs, including the Territories. The highest level consists of 2 categories that cover all of the land mass of Canada:
— Inside CMAs and CAs
— Outside CMAs and CAsStillbirth: The complete expulsion or extraction from a Person of a product of conception either after the twentieth week of pregnancy or once it has attained a weight of 500 grams or more, and where, after the expulsion or extraction, there is no breathing, heartbeat, pulsation of the umbilical cord or movement of voluntary muscles.Street Direction: The directional indicator used to qualify or distinguish a Street Name.
Note: Examples include North, North West, E, and SW.Street Name: The official label that identifies a street.
Note: The Street Name should not be translated (e.g., "Main" should not be translated to "Principal").Street Number: The number of a property on a street that an Address identifies.
Note: Street Number refers to a building on a street, not the street itself. Street Number Suffix: A suffix added to Street Number to provide unique localization.
Note: Examples include "1/4," "A" and "B."Street Type: A suffix that identifies information of the street.
Note: Examples include highway, street and avenue.Substance: A homogeneous material with a definite composition that is a constituent of medicinal and/or non-medicinal Products.
Note: Substances include therapeutic Substances administered correctly at an appropriate dosage for the individual (e.g., medications or Vaccinations); food; materials derived from plants or Animals; and venom from insect stings.Substance Strength: The concentration or potency of the Active Ingredient(s) in a Drug Product.
Note: Drug strength indicates the amount of Active Ingredients present in a specific unit or volume of the medication.Substance Strength Set: The set of Active Ingredient Substance(s), when combined with an expression of their strength.
Note: Combination Non-Proprietary Therapeutic Drug Products will have more than one Substance Strength Set.Substance Use: The consumption or intake of Substances such as tobacco and nicotine Products, vape Products, alcohol, and Regulated or unregulated drugs. This behaviour may be screened for or assessed to support clinical care and related data collection.
Note: Screening and Assessment for Substance Use have the potential to be stigmatizing. Using approaches that are non-judgmental, trauma-informed and Person-centred helps build trust and encourages honest and open communication. Suite Number: A unique number that identifies a specific room or location within a building.Suite Type: A suffix that identifies the type of room or location associated with a given Suite Number.
Note: Examples include apartment, unit and suite. Term: Represents a Concept identified by the Term Name.
Note: Each Term consists of a Name, definition, Term notes, key relationships and Aliases in both English and French.Terminology Foundation: The Code System and/or base Value Set from which curated subsets may be developed for a specific implementation or use case. Therapeutic Moiety: The functional and clinically significant part of the Active Ingredient Substance(s) present in a Drug Product.
Note: The Therapeutic Moiety is an abstract representation of a Drug Product without reference to strength and Dose form, focusing only on Active Ingredients. For example, amlodipine.Treatment: An action taken for a therapeutic, preventive, palliative, diagnostic, cosmetic or other health-related purpose. Treatment may include a course of Treatment, a Treatment plan or a community Treatment plan.Unit of Presentation: The countable Entity in which the clinical drug is presented or by which it is bounded.
Note: The Unit of Presentation is used to support the expression of strength and to differentiate between Drug Products.Vaccination: A Procedure in which a biological preparation containing immunizing agent(s) is introduced into the body to stimulate an immune response.
Note: While the Terms Immunization and Vaccination are not clinically identical, for the purposes of the Pan-Canadian Health Data Content Framework, Immunization is used to represent both Immunizations and Vaccinations.Vaccine Preventable Disease: A Disease caused by an infectious agent for which a vaccine exists to protect against.Value: The numeric and/or alphanumeric character(s) assigned to represent a specific quantity, item, Person or Organization.
Note: Examples include Organization Identifier Value, height in centimetres and phone number. Value Set: The finite set of permitted Values (Codes), drawn from 1 or more Code Systems, for a Data Element representing a Codeable Concept.
Note: A Value Set may include related Attributes such as Value source, Code Name and Code Description. Virtual Care Network: A collection of Health Care Providers and/or Organizations grouped by shared characteristics such as geography or Specialty.Vital Sign: A physiological measurement used to assess basic life-sustaining functions of the body and determine the Health Status of a Person receiving care. Well-Being: The overall state of physical, mental and social well-being of individuals and populations as influenced by material conditions, quality of life and the sustainability of Health and wellness over time.
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