OSCAR E2E Terms Reference

E2E Term	E2E Definition	OSCAR Term (UI)
Advance Directives	Living wills, healthcare proxies as well as CPR and resuscitation status.	eforms, forms
Alerts	Any condition about which a care provider should be aware. Examples of alerts could include exposure to contagious disease, the existence of an advance directive, a social situation or a fear/phobia. Other types of alerts could include Organ Donor, or a Transplant Recipient, Special needs, Patient Preferences or MRSA positive.	ticklers, decision support alerts, new demographic record alert field, drug allergy alerts
Allergies & Intolerances	Different allergies or adverse reactions that a patient may have or have had. This section is commonly referred to as the “Reaction List”.	allergies
Allergy & Intolerance Observation		allergies
Appointments & Scheduling	Appointment events. This section may be used to communicate both future and past appointments.	appointments
Billing	Billing information associated with the patient record. This section supports a single attached external file containing the billing history for the patient according to the B.C. Medical Services Plan (MSP) format6.	billing
Care Plan / Reminders / Tasks	Specific planned or scheduled tests, procedures or regimens of care to be performed by the physician or agreed upon by the patient. This section includes reminders and tasks to be performed by the care provider team.	eforms and forms for Care Plans, ticklers for Reminders and Tasks
Clinically Measured Observations	Clinically measured or noted observations on the patient and provides discrete data points on the patients’ physical attributes and measurements including information on the patients’ height, weight, blood pressure, pulse and heart sounds.	measurements
Current Medications	Only the active medications for the patient.	have to be derived from prescriptions
Developmental Observations	Metrics specific to paediatric requirements and consists of a series of observations regarding the patient. Information in this section would include birth weight and APGAR scores as well as percentile growth chart information.	eforms, forms
Devices	Any surgically implanted device or physical attachment the patient may have, for example pacemaker or limb prosthesis.
Encounter History & Notes	Encounters that the patient has had with the healthcare system as well as any clinical notes that are associated with the encounters. Encounter reports such as discharge summaries, operative reports and consult reports may be documented in this section along with information regarding the reason for the encounter and any follow- up required.	encounter
Family History	Conditions that family members have or have had in the past that may effect on the treatment of the patient.	Family History
Immunizations List		Preventions (Includes more than Immunizations)
Investigative Procedure History	Specific investigative events whose intent is not to change the state of the patient, that have been recorded in the EMR system. This section is used to communicate procedures that are undergone for investigative purposes but are not otherwise included in departmental specific sections – for example, Ultrasounds and Bone Scans may be included in the Medical Imaging Results & Reports Section and blood tests may be included in the Laboratory Results & Reports Section.	Likely in documents and / or manually recorded in various places (e.g. medical history, which may also include past medical history (i.e. previous diagnoses of note))
Laboratory Results & Reports	Results and reports for laboratory tests or procedures that were performed on the patient. A laboratory result may be documented as a report; where the report may be communicated as a standalone clinical document rather than a document section. A stand-alone laboratory report document may be attached to the patient record.	lab reports
Laboratory Observation		measurements
Medical History	Past conditions or diagnosis that the patient may have had which would have an effect on their care. It is indeed possible to enter the past Medical History as a series of problems that are now inactive; however, regardless of the EMR design, the time required to log the history as distinct inactive problems can be prohibitive and it is common clinical practice to actually capture this information as a single textual narrative.	medical history
Medical Imaging Results & Reports	Results, images and reports for medical imaging procedures that were performed on the patient including x-rays, CT Scans, MRI’s etc.	documents, edocuments
Medication Administration Event	These elements are those that describe the actual administration of the medication.	Administrations likely recorded in text, with the exclusion of immunizations.
Medication Dispense Event	These elements are those that describe the actual dispensing of the medication.	Likely in text if samples given (do not see a sample flag in prescription)
Medication Event	These data elements identify the Medication List record and the Medication/Drug that is the subject of the list entry.
Medication List	Detailed medication history for the patient. This section will include both active and historical medications and prescriptions along with any dispensing and administering information available.	Will likely need to be derived from prescriptions.
Medication Prescription Event	These data elements are related to the ordering or prescribing of the medication. This includes any instructions (for dispense or administration) that are made as part of the prescribing process.	patient drug profile
Orders & Requests	Records of orders for any diagnostic services, treatments, interventions, therapies that may have been made for the patient. This section may also be used to communicate referral orders and requests to other providers.	forms, consults and referrals
Problem List	The problem list may be viewed as the table of contents into the patient’s record.	Several locations: disease registry is the coded location. Ongoing concerns and medical history are free text.
Problem List Observation		dxresearch
Record Target (Patient)	The Patient Demographics (Record Target) includes all the information regarding the patient. This may include patient identifiers, name, address, contact information, gender, birth date and location, marital status, religion, race, ethnic group, guardians, etc.	demographic
Reproductive Observations	Metrics specific to maternity patient requirements. This section includes reproductive history summary information such as the number of term births, living children, and spontaneous abortions etc. It also includes specific pregnancy detail record information for each pregnancy including growth curve measurements of the fundus, due date and paternal information.
Risk Factors	Factors that may have a medical impact on the course of care of the patient such as smoking status, social behaviours, employment environment etc.	risk factors
Surgical Procedure History	Specific surgical or procedural events whose intent is to change the state of the patient, that have been recorded in the EMR system.
Treatment History	Treatments, therapies or care that the patient has undergone. This section is specifically designed to communicate treatments that have occurred over time with multiple encounters or episodes of care and is a combination of the scope of the Hospitalizations, Treatments and Referrals requirements.