"Adverse Event"
Data elements that meet criteria using this datatype should document the adverse event and its corresponding value set.
The relevant dateTime references the adverse event occurred.
The author dateTime references the time the adverse event was recorded.
Adverse Event
authorDateTime
The time the data element was entered into the clinical software. Note, some datatypes include both relevant dateTime and author dateTime attributes. When both are present, author dateTime is included to accommodate negation rationale.
The author dateTime addresses when an activity is documented. Documentation can occur at the beginning, during, at the end, or subsequent to the end of the activity. The author dateTime should be used only if the relevantPeriod cannot be obtained or to represent the time negation rationale is documented.
Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
facilityLocation
- "Encounter, Performed": Inpatient Admission, facility locations
- ICU (locationPeriod)
- Non-ICU Admission (locationPeriod)
- Rehab (locationPeriod)
recorder
The recorder indicates who recorded (or documented) the information (e.g., the individual or organization documenting the information). Note that FHIR modeling includes reference to asserter for concepts such as diagnosis and allergy/intolerance. Feedback from implementers and EHR vendors suggest that asserter fields default to the individual entering the information without clear evidence about how often clinicians change the default to the person who reported the information. Therefore, QDM retains a recorder attribute for the referenced QDM datatypes.
The prescriber attribute references the new QDM entities (Patient, Care Partner, Practitioner, or Organization) and any or all of the attributes of the respective QDM entity. For example, to reference that a physician who recorded a diagnosis is the same person who was the primary participant in an "Encounter, Performed" and to assure the physician’s specialty meets the measure’s requirements, the eCQM can use the Practitioner entity and its attributes. Should the eCQM choose to reference a physician practice or a hospital, the performer can reference the Organization entity and indicate the identifier and/or the organization type.
[See Section 2.6 for description of QDM entities]