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Health records
The concepts describing how care is documented: health records, extracts, reports, and the repositories that share them.
non-ratified care information
care information the relevance of which has not been assessed and explicitly stated as valid by a care professional

Health records
The concepts describing how care is documented: health records, extracts, reports, and the repositories that share them.
- record template
  information model that is a template for recording a care record
- care data
  data produced during care activities
- care information
  information about a person relevant to their care
- care documenting
  care activity where health records are created or maintained
- health record
  data repository regarding the health and care of a subject of care
- professional health record
  health record held under the responsibility of one care provider and maintained by care professionals
- personal health record
  health record held and maintained by the subject of care or a subject of care proxy
- shareable data repository
  data repository containing health record extracts, accessible for duly authorized care actors independent of their organizational affiliation and placed under the custody of a care actor
- health record extract
  part or all of a health record extracted for the purpose of communication
- social record extract
  part or all of a social record extracted for the purpose of communication
- health report
  health record extract conveying specifically focused care information in order to fulfil current information needs of the recipient
- social care report
  social record extract conveying specifically focused social care information in order to fulfil current information needs of the recipient
- discharge report
  health report concerning a completed mandated period of care
- health summary
  electronic health record extract containing essential care information intended for specific uses
- discharge summary
  discharge report summarizing a mandated period of care
- health concern
  health record extract that includes all health record components associated with a health thread
- summarized care information repository
  data repository containing summarized information for care coordination and the continuity of care
- care communication
  care activity where two or more care actors communicate
- non-ratified care information
  care information the relevance of which has not been assessed and explicitly stated as valid by a care professional
- care information for import
  care information that is a candidate for import into a professional health record after a care professional has confirmed its clinical relevance to that professional health record
- care information request
  request sent out by a care actor to another care actor for specific care information needed for the provision of care to a subject of care
- health certificate
  official document issued by a care actor attesting to the relevant health matters of a subject of care
- health record component
  part of a health record that is identifiable for the purposes of referencing and revision
- folder
  record component used for creating hierarchical structures within an electronic health record extract and with compositions as leaf nodes
- composition
  health record component containing information composed during one clinical encounter or documentation session, and committed within one health record
- entry
  health record component that represents the data documenting one observation or a series of related observations, or a statement, an explanation of reasoning, a care intention, plan or action

non-ratified care information

care information the relevance of which has not been assessed and explicitly stated as valid by a care professional

non-ratified care information extends the class care information

Table 1. Associations of non-ratified care information
Source multiplicity	Source class	Association	Target class	Target multiplicity
0..*	non-ratified care information	becomes	care information for import	1..*
0..*	non-ratified care information	recorded in	health record	1..*
0..*	automated care	results in	non-ratified care information	0..*
0..*	care third party activity	generates	non-ratified care information	0..*
1..*	self-care	generates	non-ratified care information	0..*

Figure 1. Class Diagram

Plural non-ratified care information

Note 1 It is possible that care information that has been received and is proposed for incorporation in a professional health record has not yet been reviewed for validity or context by the care professional and as such its accuracy can remain arguable. In this respect, clinical ratification differs both from attesting information for the needs of an audit trail, or from committing information in the perspective of sending out messages containing care information outlined in ISO 13606-1.

Note 2 Regardless of the technical process meant practically, care information cannot be “inserted” into a professional health record unless ratified by a care professional. Until a decision is made regarding their insertion or rejection, they are held in a secure temporary storage. An exception to this would be when a care professional would directly import care information from a shareable data repository into the local health record they hold. In the case where this import resulted from a request to the care actor in the custody of whom the shareable data repository is placed, that care information would then need validation.