Diagnosis

Type: Information Object

Status: Planned
Industry Sector: Healthcare
Sensitivity Level: Confidential
Personal Information: Sensitive PII

Description:
A clinician's determination of a patient's disease, condition or injury, coded using ICD or equivalent classification.

Accessed by Application(s):

• Clinical Coding Application
• Clinical Decision Support System
• Clinical Quality Management System
• Electronic Health Record System
• Emergency Department Information System
• Patient Portal
• Prior Authorization Management System
• Public Health Surveillance System
• Revenue Cycle Management System

 Yes

Attributes

Order	Name	Description	Type	Cardinality	Example value
1	Diagnosis ID	Unique identifier for the diagnosis record	GUID	Mandatory
2	Patient ID	Reference to the patient receiving the diagnosis	Reference	Mandatory
3	ICD Code	International Classification of Diseases code	String	Mandatory	J18.9
4	SNOMED Code	SNOMED CT clinical terminology code	String	Optional
5	Clinician ID	Reference to the clinician who made the diagnosis	Reference	Mandatory
6	Diagnosis Type	Whether the diagnosis is primary, secondary or comorbidity	Enumeration	Mandatory	Primary
7	Status	Current status of the diagnosis	Enumeration	Mandatory	Active
8	Diagnosed Date	Date the diagnosis was made	Date	Mandatory
9	Chronic	Indicates whether the condition is chronic or acute	Boolean	Optional
10	Description	Plain language description of the diagnosis	String	Mandatory

 Yes
 
 Planned
 Sensitive PII
 Confidential
 Healthcare
 A clinician's determination of a patient's disease, condition or injury, coded using ICD or equivalent classification.

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