[NO/URSA-CORE] EMR Encounter Diagnoses

Object Description

One record per diagnosis associated with an EMR encounter; includes reason for visit; does not include problem list entries added or edited during an encounter.

Metadata

• Table Name: ursa.no_ursa_core_cond_005
• Layer: NATURAL_OBJECT
• Object Type: Single Stack
• Temporal Class: Event
• Case ID: EMR Encounter Diagnosis ID
• Event Date: Encounter Start Date
• Primary Key: EMR Encounter Diagnosis ID

Published Fields

• Data Model Keys

  • EMR Encounter Diagnosis ID -- The identifier for the instance of documented diagnosis associated with an EMR Encounter.
  • EMR Encounter ID -- The internal database identifier (used, e.g., for joins and primary keys) for the EMR encounter. (See also [URSA-CORE] EMR Encounter)
  • Diagnosis Line Number -- The integer-valued ordinal representing the position of a diagnosis on a claim, bill, encounter, or other master record. May not necessarily match the analogous value in the source data for the same record. Typically, the diagnosis in the first position is considered the principal diagnosis, though this is not an absolute rule, and the Is Principal Diagnosis field should be used to identify the principal diagnosis.
  • Patient ID -- The internal database identifier (used, e.g., for joins and primary keys) for the patient. This value is typically mastered, i.e., all records for the same patient, regardless of the source data system from which that record originated, should have the same Patient ID value. (Note that while the mastered Patient ID value might resemble a local identifier used in one of the upstream data sources, this does not indicate any special priority of that source system in determining the characteristics of the patient.) (See also [URSA-CORE] Patient)
  • Document ID
  • Source ID -- The identifier for the original source data system from which the current record originated.

• Source Local Keys

  • Source Local EMR Encounter Diagnosis ID
  • Source Local EMR Encounter ID
  • Source Local Diagnosis Line Number -- The integer-valued ordinal for a diagnosis in the original source data system.

• Date Fields

  • Encounter Start Date
  • Encounter End Date

• Diagnosis Fields

  • Diagnosis Description
  • Diagnosis Operational ID
  • Diagnosis ICD-9-CM Code -- The standard ICD-9-CM diagnosis code; e.g., 001.0 = Cholera due to vibrio cholerae. ICD-9-CM diagnosis codes longer than 3 digits must include a decimal point after the 3rd digit.
  • Diagnosis ICD-9-CM Description
  • Diagnosis ICD-10-CM Code -- The standard ICD-10-CM diagnosis code; e.g., A00 = Cholera. ICD-10-CM diagnosis codes longer than 3 digits must include a decimal point after the 3rd digit.
  • Diagnosis ICD-10-CM Description
  • Diagnosis SNOMED CT Code
  • Diagnosis SNOMED CT Description
  • Body Site SNOMED CT Code
  • Body Site SNOMED CT Description
  • Is Admitting Diagnosis -- Indicates that a diagnosis was the admitting diagnosis for an encounter.
  • Is Principal Diagnosis -- Indicates that a diagnosis was documented as the principal diagnosis for the claim, bill, encounter, etc.
  • Is Diagnosis POA -- Indicates that a diagnosis was documented as present on admission (POA).

• Metadata Fields

  • Other EMR Comments -- Any other annotations or comments associated with the current record entered into the EMR.
  • Record Last Updated Datetime -- The date and time the current record was last updated in the original data source.
  • Source Data Effective Datetime -- The "as of" date and time of the original source data system at the moment the current record was extracted. For example, if a snapshot of the data in a production system is taken at 12:05 AM on the first of each month and used to generate a package of flat files that are eventually loaded into the Ursa Studio client database later that month, the Source Data Effective Datetime of all records in that month's package will be 12:05 AM on the first. Not to be confused with Record Last Updated Datetime. (See also [URSA-CORE] Record Last Updated Datetime)

Foreign Keys

• emr_enc_id → ursa.no_ursa_core_enc_001.emr_enc_id
• pat_id → ursa.no_ursa_core_pat_001.pat_id

Dedicated Precursors

• [NO/URSA-CORE] EMR Encounter Diagnoses, Precursor 1 (All Source Records): One record per diagnosis associated with an EMR encounter; does not include problem list entries