A condition represents a patient’s diagnosed and self-reported health conditions and diseases. The patient’s medical history and current state may both be represented.
Fields
Condition code. Leading zeroes and different levels of decimal precision are permissible in this field. Please populate the exact textual value of this diagnosis code, but remove source-specific suffixes and prefixes. Other codes should be listed as recorded in the source data.
stringPlease note: The “Patient-reported” category can include reporting by a proxy, such as patient’s family or guardian. Guidance: “Registry cohort” generally refers to cohorts of patients flagged with a certain set of characteristics for management within a health system. “Patient-reported” can include self-reported medical history and/or current medical conditions, not captured via healthcare problem lists or registry cohorts.
stringCondition status corresponding with REPORT_DATE. Guidance: The value of IN=Inactive may be used in situations where a condition is not resolved, but is not currently active (for example, psoriasis).
stringCondition code type. Please note: The “Other” category is meant to identify internal use ontologies and codes.
stringArbitrary encounter-level identifier used to link across tables. This is an optional field, and should only be populated if the item was collected as part of a healthcare encounter.
stringArbitrary person-level identifier. Used to link across tables.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringDate condition was noted. Please note that this date may not correspond to onset date.
stringDate condition was resolved, if resolution of a transient condition has been achieved. A resolution date is not generally expected for chronic conditions, even if the condition is managed.
stringDemographics record the direct attributes of individual patients.
Fields
Flag to indicate that one or more biobanked specimens are stored and available for research use. Examples of biospecimens could include plasma, urine, or tissue. If biospecimens are available, locally maintained “mapping tables” would be necessary to map between the DEMOGRAPHIC record and the originating biobanking system(s). If no known biobanked specimens are available, this field should be marked “No”.
stringDate of birth.
stringTime of birth.
stringA person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
stringArbitrary person-level identifier used to link across tables. PATID is a pseudoidentifier with a consistent crosswalk to the true identifier retained by the source Data Partner. For analytical data sets requiring patient-level data, only the pseudoidentifier is used to link across all information belonging to a patient. The PATID must be unique within the data source being queried. Creating a unique identifier within a CDRN would be beneficial and acceptable. The PATID is not the basis for linkages across partners.
stringPlease use only one race value per patient. Details of categorical definitions: American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American: A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringAdministrative sex. v2.0 guidance added: The “Ambiguous” category may be used for individuals who are physically undifferentiated from birth. The “Other” category may be used for individuals who are undergoing gender re-assignment.
stringDiagnosis codes indicate the results of diagnostic processes and medical coding within healthcare delivery.
Fields
Please note: This is a field replicated from the ENCOUNTER table. See the ENCOUNTER table for definitions.
stringDiagnosis code. Leading zeroes and different levels of decimal precision are permissible in this field. Please populate the exact textual value of this diagnosis code, but remove source-specific suffixes and prefixes. Other codes should be listed as recorded in the source data.
stringClassification of diagnosis source. We include these categories to allow some flexibility in implementation. The context is to capture available diagnoses recorded during a specific encounter. It is not necessary to populate interim diagnoses unless readily available. Ambulatory encounters would generally be expected to have a source of “Final.”
stringDiagnosis code type. We provide values for ICD and SNOMED code types. Other code types will be added as new terminologies are more widely used. Please note: The “Other” category is meant to identify internal use ontologies and codes.
stringPlease note: This is a field replicated from the ENCOUNTER table. See the ENCOUNTER table for definitions.
stringArbitrary encounter-level identifier. Used to link across tables.
stringArbitrary person-level identifier. Used to link across tables.
stringPrincipal discharge diagnosis flag. Relevant only on IP and IS encounters. For ED, AV, and OA encounter types, mark as X = Unable to Classify. (Billing systems do not require a primary diagnosis for ambulatory visits (eg, professional services)) One principal diagnosis is expected, although in some instances more than one diagnosis may be flagged as principal.
stringPlease note: This is a field replicated from the ENCOUNTER table. See the ENCOUNTER table for definitions.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOutpatient pharmacy dispensing, such as prescriptions filled through a neighborhood pharmacy with a claim paid by an insurer. Outpatient dispensing is not commonly captured within healthcare systems.
Fields
Number of units (pills, tablets, vials) dispensed. Net amount per NDC per dispensing. This amount is typically found on the dispensing record. Positive values are expected. Important: Please do not calculate during CDM implementation. This field should only reflect originating source system calculations.
numberDispensing date (as close as possible to date the person received the dispensing).
stringDays supply. Number of days that the medication supports based on the number of doses as reported by the pharmacist. This amount is typically found on the dispensing record. Integer values are expected. Important: Please do not calculate during CDM implementation. This field should only reflect originating source system calculations.
numberNational Drug Code in the 11-digit, no-dash, HIPAA format. Please expunge any place holders (such as dashes or extra digits). If needed, guidance on normalization for other forms of NDC can be found: http://www.nlm.nih.gov/research/umls/rxnorm/docs/2012/rxnorm_doco_full_2012-1.html (see section 6)
stringArbitrary person-level identifier. Used to link across tables.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringEncounters are interactions between patients and providers within the context of healthcare delivery.
Fields
Encounter or admission date.
stringEncounter or admission time.
stringAdmitting source. Should be populated for Inpatient Hospital Stay (IP) and Non-Acute Institutional Stay (IS) encounter types. May be populated for Emergency Department (ED) encounter types. Should be missing for ambulatory visit (AV or OA) encounter types.
stringDischarge date. Should be populated for all Inpatient Hospital Stay (IP) and Non-Acute Institutional Stay (IS) encounter types. May be populated for Emergency Department (ED) encounter types. Should be missing for ambulatory visit (AV or OA) encounter types.
stringVital status at discharge. Should be populated for Inpatient Hospital Stay (IP) and Non-Acute Institutional Stay (IS) encounter types. May be populated for Emergency Department (ED) encounter types. Should be missing for ambulatory visit (AV or OA) encounter types.
stringDischarge status. Should be populated for Inpatient Hospital Stay (IP) and Non-Acute Institutional Stay (IS) encounter types. May be populated for Emergency Department (ED) encounter types. Should be missing for ambulatory visit (AV or OA) encounter types.
stringDischarge time.
string3-digit Diagnosis Related Group (DRG). Should be populated for IP and IS encounter types. May be populated for ED encounter types. Should be missing for AV or OA encounters. Use leading zeroes for codes less than 100. The DRG is used for reimbursement for inpatient encounters. It is a Medicare requirement that combines diagnoses into clinical concepts for billing. Frequently used in observational data analyses.
stringDRG code version. MS-DRG (current system) began on 10/1/2007. Should be populated for IP and IS encounter types. May be populated for ED encounter types. Should be missing for AV or OA encounters.
stringEncounter type. Details of categorical definitions: Ambulatory Visit: Includes visits at outpatient clinics, physician offices, same day/ambulatory surgery centers, urgent care facilities, and other same-day ambulatory hospital encounters, but excludes emergency department encounters. Emergency Department (ED): Includes ED encounters that become inpatient stays (in which case inpatient stays would be a separate encounter). Excludes urgent care visits. ED claims should be pulled before hospitalization claims to ensure that ED with subsequent admission won’t be rolled up in the hospital event. Emergency Department Admit to Inpatient Hospital Stay: Permissible substitution for preferred state of separate ED and IP records. Only for use with data sources where the individual records for ED and IP cannot be distinguished (new to v2.0). Inpatient Hospital Stay: Includes all inpatient stays, including: same-day hospital discharges, hospital transfers, and acute hospital care where the discharge is after the admission date. Non-Acute Institutional Stay: Includes hospice, skilled nursing facility (SNF), rehab center, nursing home, residential, overnight non-hospital dialysis and other non-hospital stays. Other Ambulatory Visit: Includes other non-overnight AV encounters such as hospice visits, home health visits, skilled nursing facility visits, other non-hospital visits, as well as telemedicine, telephone and email consultations. May also include “lab only” visits (when a lab is ordered outside of a patient visit), “pharmacy only” (e.g., when a patient has a refill ordered without a face-to-face visit), “imaging only”, etc.
stringArbitrary encounter-level identifier. Used to link across tables, including the ENCOUNTER, DIAGNOSIS, and PROCEDURE tables.
stringGeographic location (3 digit zip code). Should be left blank if not recorded in source system.
stringArbitrary local facility code that identifies the hospital or clinic. Used for chart abstraction and validation. FACILITYID can be a true identifier, or a pseudoidentifier with a consistent crosswalk to the true identifier retained by the source Data Partner.
stringArbitrary person-level identifier used to link across tables.
stringProvider code for the provider who is most responsible for this encounter. For encounters with multiple providers choose one so the encounter can be linked to the diagnosis and procedure tables. As with the PATID, the provider code is a pseudoidentifier with a consistent crosswalk to the real identifier.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringThis field is new to v2.0. Optional field for locally-defined identifier intended for local use; for example, where a network may have multiple sites contributing to a central data repository. This attribute may be sensitive in certain contexts; the intent is for internal network use only, and not to enable site quality comparisons.
stringEnrollment is a concept that defines a period of time during which all medically-attended events are expected to be observed. This concept is often insurance-based, but other methods of defining enrollment are possible.
Fields
Chart abstraction flag is intended to answer the question, “Are you able to request (or review) charts for this person?” This flag does not address chart availability. Mark as “Yes” if there are no contractual or other restrictions between you and the individual (or sponsor) that would prohibit you from requesting any chart for this member. Note: This field is most relevant for health insurers that can request charts from affiliated providers. This field allows exclusion of patients from studies that require chart review to validate exposures and/or outcomes. It identifies patients for whom charts are never available and for whom the chart can never be requested.
stringWhen insurance information is not available but complete capture can be asserted some other way, please identify the basis on which complete capture is defined. Additional information on the approach identified will be required from each partner. ENR_BASIS is a property of the time period defined. A patient can have multiple entries in the table. Details of categorical definitions: Insurance: The start and stop dates are based upon the concept of enrollment with health plan insurance Geography: An assertion of complete data capture between the start and end dates based upon geographic characteristics, such as regional isolation Algorithmic: An assertion of complete data capture between the start and end dates, based on a locally developed or applied algorithm, often using multiple criteria Encounter-based: The start and stop dates are populated from the earliest-observed encounter and latest-observed encounter.
stringDate of the end of the enrollment period. If the exact date is unknown, use the last day of the month.
stringDate of the beginning of the enrollment period. If the exact date is unknown, use the first day of the month. For implementation of the CDM, a long span of longitudinal data is desirable; however, especially for historical data more than a decade old, the appropriate beginning date should be determined by the partner’s knowledge of the validity and usability of the data. More specific guidance can be provided through implementation discussions.
stringArbitrary person-level identifier used to link across tables.
stringLaboratory result Common Measures (CM) use specific types of quantitative and qualitative measurements from blood and other body specimens. These standardized measures are defined in the same way across all PCORnet networks.
Fields
Abnormal result indicator. This value comes from the source data; do not apply logic to create it.
stringArbitrary encounter-level identifier used to link across tables. This is an optional field, and should only be populated if the lab was collected as part of a healthcare encounter.
stringLogical Observation Identifiers, Names, and Codes (LOINC) from the Regenstrief Institute. Results with local versions of LOINC codes (e.g., LOINC candidate codes) should be included in the RAW_table field, but the LOINC variable should be set to missing. Current LOINC codes are from 3-7 characters long but Regenstrief suggests a length of 10 for future growth. The last digit of the LOINC code is a check digit and is always preceded by a hyphen. All parts of the LOINC code, including the hyphen, must be included. Do not pad the LOINC code with leading zeros. Please see the LOINC reference table for known LOINC codes for each LAB_NAME.
stringLaboratory result common measure, a categorical identification for the type of test, which is harmonized across all contributing data partners. Please note that it is possible for more than one LOINC code, CPT code, and/or local code to be associated with one LAB_NAME.
stringDate test was ordered.
stringOptional variable for local and standard procedure codes, used to identify the originating order for the lab test.
stringProcedure code type, if applicable.
stringModifier for NORM_RANGE_HIGH values. For numeric results one of the following needs to be true: 1) Both MODIFIER_LOW and MODIFIER_HIGH contain EQ (e.g. normal values fall in the range 3-10) 2) MODIFIER_LOW contains GT or GE and MODIFIER_HIGH contains NO (e.g. normal values are >3 with no upper boundary) 3) MODIFIER_HIGH contains LT or LE and MODIFIER_LOW contains NO (e.g. normal values are <=10 with no lower boundary)
stringModifier for NORM_RANGE_LOW values. For numeric results one of the following needs to be true: 1) Both MODIFIER_LOW and MODIFIER_HIGH contain EQ (e.g. normal values fall in the range 3-10) 2) MODIFIER_LOW contains GT or GE and MODIFIER_HIGH contains NO (e.g. normal values are >3 with no upper boundary) 3) MODIFIER_HIGH contains LT or LE and MODIFIER_LOW contains NO (e.g. normal values are <=10 with no lower boundary)
stringUpper bound of the normal range assigned by the laboratory. Value should only contain the value of the upper bound. The symbols >, <, >=, <= should be removed. For example, if the normal range for a test is >100 and <300, then “300” should be entered.
stringLower bound of the normal range assigned by the laboratory. Value should only contain the value of the lower bound. The symbols >, <, >=, <= should be removed. For example, if the normal range for a test is >100 and <300, then “100” should be entered.
stringArbitrary person-level identifier. Used to link across tables.
stringImmediacy of test. The intent of this variable is to determine whether the test was obtained as part of routine care or as an emergent/urgent diagnostic test (designated as Stat or Expedite).
stringLocal facility code that identifies the hospital or clinic. Taken from facility claims.
stringLocal code related to an individual lab test. This variable will not be used in queries, but may be used by local programmers to associate a record with a particular LAB_NAME.
stringLocal code related to an individual lab test. This variable will not be used in queries, but may be used by local programmers to associate a record with a particular LAB_NAME.
stringLocal code for ordering provider department.
stringLocal code related to a battery or panel of lab tests. This variable will not be used in queries, but may be used by local programmers to associate a record with a particular LAB_NAME.
stringThe original test result value as seen in your source data. Values may include a decimal point, a sign or text (e.g., POSITIVE, NEGATIVE, DETECTED). The symbols >, <, >=, <= should be removed from the value and stored in the Modifier variable instead.
stringOriginal units for the result in your source data.
stringResult date.
stringLocation of the test result. Point of Care locations may include anticoagulation clinic, newborn nursery, finger stick in provider office, or home. The default value is ‘L’ unless the result is Point of Care. There should not be any missing values.
stringModifier for result values. Any symbols in the RAW_RESULT value should be reflected in the RESULT_MODIFIER variable. For example, if the original source data value is “<=200” then RAW_RESULT=200 and RESULT_MODIFIER=LE. If the original source data value is text then RESULT_MODIFIER=TX. If the original source data value is a numeric value then RESULT_MODIFIER=EQ.
stringStandardized/converted result for quantitative results. This variable should be left blank for qualitative results. Please see the reference tables for additional details.
integerStandardized result for qualitative results. This variable should be NI for quantitative results. Please see the reference tables for additional details and information on acceptable values for each qualitative LAB_NAME.
stringResult time.
stringConverted/standardized units for the result. Please see the standard abbreviations reference table for additional details.
stringDate specimen was collected.
stringSpecimen source. All records will have a specimen source; some tests have several possible values for SPECIMEN_SOURCE. Please see the reference tables for additional details.
stringTime specimen was collected.
stringPatient-reported outcome Common Measures are standardized measures that are defined in the same way across all PCORnet networks. Each measure is recorded at the individual item level: an individual question/statement, paired with its standardized response options.
Fields
Arbitrary encounter-level identifier used to link across tables. This is an optional field, and should only be populated if the item was collected as part of a healthcare encounter.
stringArbitrary person-level identifier for the patient for whom the PRO response was captured. Used to link across tables.
stringIndicates whether Computer Adaptive Testing (CAT) was used to administer the survey or instrument that the item was part of. May apply to electronic (EC) and telephonic (PH or IV) modes.
stringThe date of the response.
stringPCORnet identifier for the specific Common Measure item. Please see the Common Measures reference table for more details.
stringLOINC code for item context and stem. Please see the reference table for known LOINC codes for each common measure. Logical Observation Identifiers, Names, and Codes (LOINC) from the Regenstrief Institute. Results with local versions of LOINC codes (e.g., LOINC candidate codes) should be included in the RAW_table field, but the PRO_LOINC variable should be set to missing. Current LOINC codes are from 3-7 characters long but Regenstrief suggests a length of 10 for future growth. The last digit of the LOINC code is a check digit and is always preceded by a hyphen. All parts of the LOINC code, including the hyphen, must be included. Do not pad the LOINC code with leading zeros.
stringMethod of administration. Electronic includes responses captured via a personal or tablet computer, at web kiosks, or via a smartphone.
stringThe person who responded on behalf of the patient for whom the response was captured. A proxy report is a measurement based on a report by someone other than the patient reporting as if he or she is the patient, such as a parent responding for a child, or a caregiver responding for an individual unable to report for themselves. Assistance excludes providing interpretation of the patient’s response.
stringThe numeric response recorded for the item. Please see the Common Measures reference table for the list of valid responses for each item.
numberThe time of the response.
stringOptional field for originating code, such as LOINC candidate codes that have not yet been adopted
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringProcedure codes indicate the discreet medical interventions and diagnostic testing, such as surgical procedures, administered within healthcare delivery.
Fields
Please note: This is a field replicated from the ENCOUNTER table. See ENCOUNTER table for definitions.
stringPlease note: This is a field replicated from the ENCOUNTER table. See ENCOUNTER table for definitions.
stringArbitrary encounter-level identifier. Used to link across tables.
stringArbitrary person-level identifier. Used to link across tables.
stringPlease note: This is a field replicated from the ENCOUNTER table. See ENCOUNTER table for definitions.
stringProcedure code.
stringNew to v2.0. Date the procedure was performed.
stringNew to v2.0. Source of the procedure information. Order and billing pertain to internal healthcare processes and data sources. Claim pertains to data from the bill fulfillment, generally data sources held by insurers and other health plans.
stringProcedure code type. We include a number of code types for flexibility, but the basic requirement that the code refer to a medical procedure remains. Revenue codes are a standard concept in Medicare billing and can be useful for defining care settings. If those codes are available they can be included. Medications administered by clinicians can be captured in billing data and Electronic Health Records (EHRs) as HCPCS procedure codes. Administration (infusion) of chemotherapy is an example. We are now seeing NDCs captured as part of procedures because payers are demanding it for payment authorization. Inclusion of this code type enables those data partners that capture the NDC along with the procedure to include the data. Please note: The “Other” category is meant to identify internal use ontologies and codes.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringVital signs (such as height, weight, and blood pressure) directly measure an individual’s current state of attributes.
Fields
Position for orthostatic blood pressure. Leave blank if blood pressure was not measured.
stringDiastolic blood pressure (in mmHg). Only populated if measure was taken on this date. If missing, leave blank.
numberArbitrary encounter-level identifier. This is an optional relationship; the ENCOUNTERID should be present if the vitals were measured as part of healthcare delivery.
stringHeight (in inches) measured by standing. Only populated if measure was taken on this date. If missing, leave blank. Decimal precision is permissible.
numberDate of vitals measure.
stringTime of vitals measure.
stringBMI if calculated in the source system. Important: Please do not calculate BMI during CDM implementation. This field should only reflect originating source system calculations, if height and weight are not stored in the source.
numberArbitrary person-level identifier. Used to link across tables.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set.
stringOptional field for originating value of field, prior to formatting into the PCORnet CDM.
stringOptional field for originating value of field, prior to formatting into the PCORnet CDM.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set. New to v2.0.
stringOptional field for originating value of field, prior to mapping into the PCORnet CDM value set. New to v2.0.
stringSystolic blood pressure (in mmHg). Only populated if measure was taken on this date. If missing, leave blank.
numberThis field is new to v2.0. Guidance: The values of “Heavy tobacco smoker” and “Light tobacco smoker” will be assumed to imply a smoking status of current.
stringThis field is new to v2.0. Type(s) of tobacco used.
stringPlease note: The “Patient-reported” category can include reporting by patient’s family or guardian. v2.0 amendment: The new categorical value of PD and HD have been added. v2.0 guidance added: If unknown whether data are received directly from a device feed, use the more general context (such as patient-reported, healthcare delivery setting, or registry).
stringWeight (in pounds). Only populated if measure was taken on this date. If missing, leave blank. Decimal precision is permissible.
number