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Data Elements Framework (Illustrative)

Organization of the Framework

For ease of reference, the Healthcare Data Elements are organized into nine logical categories (A–I). Each category groups related healthcare information according to its primary purpose while maintaining a single standardized numbering structure across the entire framework.

This standardized organization demonstrates how individual Healthcare Data Elements can be systematically assembled into different healthcare documents while preserving the meaning, consistency, and re-usability of healthcare information throughout the patient's healthcare journey.

Notes

The Healthcare Data Elements presented in this supplement are intended for illustration and discussion purposes only. The final Data Elements, classifications, definitions, numbering, specialty-specific extensions, and governance should be developed, reviewed, approved, and periodically maintained by the respective multidisciplinary expert panels.

A. Patient Identification (001–018)

  1. Unique Patient ID (UHID)
  2. ABHA Number
  3. First Name
  4. Middle Name
  5. Last Name
  6. Date of Birth
  7. Age
  8. Gender
  9. Photograph
  10. Blood Group
  11. Nationality (medical tourist)
  12. Marital Status
  13. Preferred Language
  14. Occupation
  15. Government ID Type
  16. Government ID Number
  17. Bio-metric Identifier (optional)
  18. Patient Status (New / Existing)

B. Contact Information (019–032)

  1. Mobile Number
  2. Alternate Mobile
  3. Email
  4. Address (Local)
  5. Address (tourist)
  6. Emergency Contact Name
  7. Relationship
  8. Emergency Contact Number
  9. Alternate Emergency Contact
  10. Family Physician
  11. Preferred Language for Communication
  12. Preferred Contact Method
  13. Consent to Email
  14. Contact Remarks

C. Administrative Information (033–052)

  1. Registration Date
  2. Registration Time
  3. Healthcare Facility
  4. Department
  5. Unit
  6. Visit Type
  7. Consultant
  8. Referring Doctor
  9. Referral Source
  10. Appointment Number
  11. Visit Number
  12. Insurance Type
  13. Insurance Company
  14. Policy Number
  15. Government Scheme
  16. Payment Category
  17. Admission Number
  18. Case Number
  19. Encounter Number
  20. Encounter Status

D. Clinical & Encounter Information (053–082)

  1. Chief Complaint
  2. History of Present Illness
  3. Vital Signs
  4. Physical Examination
  5. Clinical Notes
  6. Provisional Diagnosis
  7. Final Diagnosis
  8. Differential Diagnosis
  9. Treatment Plan
  10. Follow-up Advice
  11. Admission Date
  12. Admission Time
  13. Ward
  14. Room
  15. Bed Number
  16. Treating Consultant
  17. Clinical Specialty
  18. Procedure Performed
  19. Procedure Date
  20. Discharge Date
  21. Discharge Summary
  22. Outcome
  23. Referral Advice
  24. Review Date
  25. Observation Notes
  26. Nursing Notes
  27. Rehabilitation Notes
  28. Clinical Alerts
  29. Infection Status
  30. Isolation Requirement

E. Patient Health Profile (083–122)

  1. Past Medical History
  2. Past Surgical History
  3. Current Medical Problems
  4. Current Medications
  5. Medication Allergies
  6. Food Allergies
  7. Other Allergies
  8. Family Medical History
  9. Genetic / Inherited Disorders
  10. Previous Hospitalizations
  11. Pregnancy History
  12. Childbirth History
  13. Vaccination History
  14. Height
  15. Weight
  16. BMI
  17. Smoking Status
  18. Alcohol Consumption
  19. Tobacco Use
  20. Recreational Drug Use
  21. Exercise Level
  22. Dietary Pattern
  23. Sleep Pattern
  24. Occupation Risk
  25. Organ Donor Status
  26. Advance Directive
  27. Primary Care Physician
  28. Preferred Pharmacy
  29. Medical Devices / Implants
  30. Travel History
  31. Disability Status
  32. Vision Impairment
  33. Hearing Impairment
  34. Speech Impairment
  35. Mobility Status
  36. Fall Risk
  37. Communication Preference
  38. Cultural / Religious Considerations
  39. Social Support
  40. Other Permanent Health Information

F. Investigations (123–142)

  1. Laboratory Test Requested
  2. Laboratory Results
  3. Radiology Requested
  4. Radiology Reports
  5. Medical Images
  6. ECG
  7. Cardiology Tests
  8. Pulmonary Function Tests
  9. Pathology Specimen
  10. Microbiology
  11. Histopathology
  12. Genetic Testing
  13. Test Date
  14. Reporting Laboratory
  15. Reporting Radiologist
  16. Report Status
  17. Critical Result Flag
  18. Comparison with Previous Results
  19. Attachments
  20. Investigation Remarks

G. Medication & Treatment (143–162)

  1. Medication Prescribed
  2. Dose
  3. Route
  4. Frequency
  5. Duration
  6. Medication Changes
  7. Medication Discontinued
  8. Pharmacy Dispensing
  9. Medication Compliance
  10. Adverse Drug Reaction
  11. Procedures Ordered
  12. Rehabilitation Plan
  13. Diet Advice
  14. Lifestyle Advice
  15. Home Care Instructions
  16. Follow-up Medication
  17. Medical Equipment
  18. Patient Education
  19. Clinical Consent
  20. Treating Team Signature

H. OPD - Consultation & Clinical Decision-Making (163–169)

  1. Consultation Type
  2. Presenting Problem
  3. Symptom Duration
  4. Clinical Impression
  5. Risk Assessment
  6. Working Diagnosis
  7. Consultation Outcome

I. Diagnostics Generic Investigation Elements (170–182)

  1. Test Requested
  2. Sample
  3. Collection Date
  4. Result
  5. Reference Range
  6. Critical Flag
  7. Reporting Professional
  8. Report Date
  9. Attachment
  10. Sample Bar Code
  11. Interpretation
  12. Method
  13. Machine

The Data Elements presented in this supplement illustrate a standardized foundation for healthcare information. Additional specialty-specific Data Elements may be developed by the respective multidisciplinary expert panels while maintaining consistency with the National Healthcare Data Elements Framework.

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