# Vercy AI instruction - YAML 1.2 (JSON-compatible) { "vercy": "1.0-draft", "publication": { "status": "published", "adjudicationStatus": "reviewable-draft", "publishableCanonical": false, "generatedAt": "2026-09-06T10:07:32Z", "synthesisSha256": "ce8dc58bfe21a9ad396d75c6f8a4850d926f4a15cef9d2f7b2117d6cc27e4758", "providerMode": "single-provider-waiver", "providers": [ "Codex" ], "waivedProviders": [ "Claude", "Grok" ] }, "metaModel": { "id": "WM-ACT-049", "registryId": "vr.wm-act-049", "name": "Care Plan / Episode", "version": "0.3.0-research.1", "previousVersions": [], "entryKind": "aggregate", "family": "World Models", "category": "Activities and processes", "industry": [ "Cross-industry" ], "domain": [ "ACT.HCR" ], "tags": [ "care", "plan", "episode", "act.hcr" ], "status": "published" }, "canonicalUrl": "https://ver.cy/models/wm-act-049-care-plan-episode/", "sourceUrl": "https://github.com/ver-cy/world-models/tree/feat/mega-model-registry/publications/wm-act-049-care-plan-episode", "model": { "registry_id": "vr.wm-act-049", "model_id": "WM-ACT-049", "name": "Care Plan / Episode", "entry_kind": "aggregate", "purpose": "Represent a governed care-context aggregate so agents can distinguish subject-specific planning from provider episode responsibility while connecting goals, participants, intended activities, progress and transitions without treating intent as performance or outcome.", "scope_statement": "Owns aggregate identity and links between a care-plan record and an episode-of-care record, plus subject-specific goals, participant-role assertions, coordination context, progress summaries, transition assertions and correction lineage. Each constituent keeps independent identity, source, status, authority and times. Patient, practitioner, organization, condition, observation, encounter, consent, reusable protocol, request, task, appointment, procedure, medication, communication, adverse-event, provenance, audit and record masters remain external.", "in_scope": [ "Aggregate, care-plan and episode identity; subject and setting; concerns, goals, targets and preferences; care-team and responsibility bindings; intended activity references and dependencies", "Independent statuses and times; progress and performed-event links; referral, handoff, transfer and closure context; correction, privacy, retention and loss-aware projections" ], "out_of_scope": [ "Independent patient, practitioner, organization, condition, observation, encounter, consent, protocol, request, task, appointment, procedure, medication, communication, adverse-event, provenance, audit and record lifecycles", "Treating a plan as performed care, an episode as an encounter, a goal as an observation, a status as clinical outcome or an association as causation", "Providing diagnosis, care authorization, treatment change, clinical assignment, workflow execution, outcome inference or medical advice" ], "boundary_notes": [ { "neighbor": "FHIR CarePlan and EpisodeOfCare", "distinction": "CarePlan is a planning request and EpisodeOfCare tracks provider association and responsibility. Each retains its own identity, status and period inside the aggregate.", "source_refs": [ "SRC-001", "SRC-002" ] }, { "neighbor": "Encounter, Task, Request and performed clinical events", "distinction": "Encounters record activities, Tasks track work, Requests authorize intent and performed-event records evidence occurrence. The aggregate stores typed references and coordination context only.", "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008" ] }, { "neighbor": "Goal, Condition, ClinicalImpression and Observation", "distinction": "Goals own desired states, conditions own concerns, clinical impressions own assessment reasoning and observations own measurements. The aggregate links them without copying clinical assertion lifecycles.", "source_refs": [ "SRC-003", "SRC-009", "SRC-010", "SRC-011" ] }, { "neighbor": "CareTeam, patient, practitioner and organization masters", "distinction": "CareTeam owns dynamic participant membership and roles; party masters own identity. The aggregate records plan and episode role bindings, responsibility and effective periods.", "source_refs": [ "SRC-001", "SRC-002", "SRC-004" ] }, { "neighbor": "PlanDefinition, RequestOrchestration and openEHR Task Planning", "distinction": "Reusable protocols and detailed executable orchestration stay external. The aggregate records versioned instantiation, coordination constraints and deviations; the openEHR source is retired and is not a conformance target.", "source_refs": [ "SRC-005", "SRC-006", "SRC-008", "SRC-016" ] }, { "neighbor": "WM-LIV-021, WM-ACT-047 and WM-ACT-048", "distinction": "Condition, procedure and medication references may supply care context, but all three registry relations remain candidate, transfer no lifecycle ownership and permit no cascade mutation.", "source_refs": [ "SRC-001", "SRC-002", "SRC-010" ] } ] }, "sources": [ { "id": "SRC-001", "title": "FHIR R5 CarePlan", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/careplan.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines a planning request that groups intended care, goals, participants and activity references for a subject over a period without owning execution." }, { "id": "SRC-002", "title": "FHIR R5 EpisodeOfCare", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/episodeofcare.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines the time-bounded association and responsibility of a provider organization for a patient, status history and links to encounters, and distinguishes tracking from planning." }, { "id": "SRC-003", "title": "FHIR R5 Goal", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/goal.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines a subject-specific desired state with lifecycle, achievement status, priority, targets, due time, source, addresses and outcome links." }, { "id": "SRC-004", "title": "FHIR R5 CareTeam", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/careteam.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines dynamic people and organizations intended to coordinate and deliver care, participant roles, periods and on-behalf-of relationships." }, { "id": "SRC-005", "title": "FHIR R5 RequestOrchestration", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/requestorchestration.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 4 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines related subject-specific requests, hierarchical action groups, conditions, optionality and dependencies while each request retains its own lifecycle." }, { "id": "SRC-006", "title": "FHIR R5 PlanDefinition", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/plandefinition.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 4 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines reusable protocols, order sets and decision artifacts that may be instantiated for a subject; it is distinct from a subject-specific care plan." }, { "id": "SRC-007", "title": "FHIR R5 Task", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/task.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 3 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines a work item and its fulfillment state, requester, owner, focus, inputs and outputs; it separates execution tracking from request authorization." }, { "id": "SRC-008", "title": "FHIR R5 Workflow", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/workflow.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines workflow state, relationships and coordination patterns and warns that interoperable data exchange does not by itself standardize process execution." }, { "id": "SRC-009", "title": "FHIR R5 ClinicalImpression", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/clinicalimpression.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 1 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines an attributable clinical assessment and reasoning record that may precede or revise a care plan without becoming the plan itself." }, { "id": "SRC-010", "title": "FHIR R5 Condition", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/condition.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 5 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines conditions, problems and concerns with separate clinical and verification states; a plan references rather than owns these clinical assertions." }, { "id": "SRC-011", "title": "FHIR R5 Observation", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/observation.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Normative from FHIR 4.0.0", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines measurements and simple assertions used to establish baselines and evaluate progress, with source, method, time, value and interpretation." }, { "id": "SRC-012", "title": "Continuity and coordination of care", "organization": "World Health Organization", "url": "https://www.who.int/publications/i/item/9789241514033", "version_or_date": "WHO practice brief, 7 November 2018", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Supports relational, informational and management continuity, coordinated transitions and person-centred care across settings and time." }, { "id": "SRC-013", "title": "UHC service planning and models of care", "organization": "World Health Organization", "url": "https://www.who.int/teams/integrated-health-services/clinical-services-and-systems/service-organizations-and-integration", "version_or_date": "Living official page accessed 6 September 2026", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Supports integrated, coordinated and people-centred service models aligned to individual and community needs across providers and settings." }, { "id": "SRC-014", "title": "Shared decision making", "organization": "National Institute for Health and Care Excellence", "url": "https://www.nice.org.uk/guidance/ng197", "version_or_date": "NICE guideline NG197, published 17 June 2021", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines shared treatment and care decisions, communication of benefits, risks and consequences, decision aids and organizational support." }, { "id": "SRC-015", "title": "Dynamic Care Planning", "organization": "Integrating the Healthcare Enterprise", "url": "https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_DCP.pdf", "version_or_date": "IHE PCC Supplement, revised 27 September 2019", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Defines interoperable dynamic care-plan sharing, contributors, goals, interventions and updates while remaining an implementation profile rather than universal clinical policy." }, { "id": "SRC-016", "title": "Task Planning Specification", "organization": "openEHR Foundation", "url": "https://specifications.openehr.org/releases/PROC/latest/task_planning.html", "version_or_date": "PROC Release-1.7.0, RETIRED, copyright 2017-2024", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Provides useful planning concepts such as teams, recurring tasks, decision pathways, cancellation and plan tracking, but its retired status requires an explicit non-conformance hold." }, { "id": "SRC-017", "title": "Regulation (EU) 2016/679 General Data Protection Regulation", "organization": "European Union", "url": "https://eur-lex.europa.eu/eli/reg/2016/679/oj", "version_or_date": "27 April 2016, applicable from 25 May 2018", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Provides purpose limitation, minimization, accuracy, security, access and correction safeguards for sensitive care-plan and episode data." }, { "id": "SRC-018", "title": "PROV-O: The PROV Ontology", "organization": "World Wide Web Consortium", "url": "https://www.w3.org/TR/prov-o/", "version_or_date": "W3C Recommendation, 30 April 2013", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Provides entity, activity, agent, attribution, delegation, derivation, revision, generation and invalidation semantics for plans and episode records." }, { "id": "SRC-019", "title": "Date and Time on the Internet: Timestamps", "organization": "Internet Engineering Task Force", "url": "https://www.rfc-editor.org/info/rfc3339/", "version_or_date": "RFC 3339, July 2002", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T10:03:00Z", "relevance": "Provides interoperable timestamps with seconds and explicit UTC relationship for clinical, planning, transition, record and knowledge times." } ], "structure": { "bundles": [ { "id": "aggregate-identity-boundary-and-constituent-types", "name": "Aggregate identity, boundary and constituent types", "description": "Groups governed care context for aggregate identity, boundary and constituent types.", "rationale": "The useful aggregate connects a planning record and a responsibility-tracking episode without collapsing their identities or states.", "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-018" ], "layers": [ { "id": "aggregate-profile-identifiers-versions-sources-and-lineage", "name": "Aggregate profile, identifiers, versions, sources and lineage", "description": "Groups source-qualified care context for aggregate profile, identifiers, versions, sources and lineage.", "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ], "findings": [ { "id": "care-context-aggregate-profile-and-plan-episode-constituent-kinds", "name": "Care context aggregate profile and plan or episode constituent kinds", "description": "Records care context aggregate profile and plan or episode constituent kinds as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ], "questions": [ { "id": "care-context-aggregate-profile-and-plan-episode-constituent-kinds-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish care context aggregate profile and plan or episode constituent kinds?", "kind": "classification", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "care-context-aggregate-profile-and-plan-episode-constituent-kinds-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by care context aggregate profile and plan or episode constituent kinds, with which role, authority, preference and limits?", "kind": "composition", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "care-context-aggregate-profile-and-plan-episode-constituent-kinds-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to care context aggregate profile and plan or episode constituent kinds, and how is it validated or corrected?", "kind": "privacy", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "care-context-aggregate-profile-and-plan-episode-constituent-kinds-data", "name": "Care context aggregate profile and plan or episode constituent kinds data", "description": "Typed data for care context aggregate profile and plan or episode constituent kinds with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ] } ], "artifacts": [ { "id": "care-context-aggregate-profile-and-plan-episode-constituent-kinds-record", "name": "Care context aggregate profile and plan or episode constituent kinds record", "description": "Immutable or successor-versioned evidence for care context aggregate profile and plan or episode constituent kinds.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for care-context-aggregate-profile-and-plan-episode-constituent-kinds; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ] } ], "inline_only_rationale": null }, { "id": "aggregate-plan-and-episode-identifiers-versions-sources-and-lineage", "name": "Aggregate, plan and episode identifiers, versions, sources and lineage", "description": "Records aggregate, plan and episode identifiers, versions, sources and lineage as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ], "questions": [ { "id": "aggregate-plan-and-episode-identifiers-versions-sources-and-lineage-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish aggregate, plan and episode identifiers, versions, sources and lineage?", "kind": "identity", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "aggregate-plan-and-episode-identifiers-versions-sources-and-lineage-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by aggregate, plan and episode identifiers, versions, sources and lineage, with which role, authority, preference and limits?", "kind": "evidence", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "aggregate-plan-and-episode-identifiers-versions-sources-and-lineage-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to aggregate, plan and episode identifiers, versions, sources and lineage, and how is it validated or corrected?", "kind": "lifecycle", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "aggregate-plan-and-episode-identifiers-versions-sources-and-lineage-data", "name": "Aggregate, plan and episode identifiers, versions, sources and lineage data", "description": "Typed data for aggregate, plan and episode identifiers, versions, sources and lineage with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ] } ], "artifacts": [ { "id": "aggregate-plan-and-episode-identifiers-versions-sources-and-lineage-record", "name": "Aggregate, plan and episode identifiers, versions, sources and lineage record", "description": "Immutable or successor-versioned evidence for aggregate, plan and episode identifiers, versions, sources and lineage.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for aggregate-plan-and-episode-identifiers-versions-sources-and-lineage; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ] } ], "inline_only_rationale": null } ] }, { "id": "subject-scope-care-setting-and-plan-episode-encounter-boundary", "name": "Subject, scope, care setting and plan, episode or encounter boundary", "description": "Groups source-qualified care context for subject, scope, care setting and plan, episode or encounter boundary.", "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013" ], "findings": [ { "id": "subject-population-care-setting-category-title-description-and-period", "name": "Subject, population, care setting, category, title, description and period", "description": "Records subject, population, care setting, category, title, description and period as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013" ], "questions": [ { "id": "subject-population-care-setting-category-title-description-and-period-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish subject, population, care setting, category, title, description and period?", "kind": "definition", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "subject-population-care-setting-category-title-description-and-period-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by subject, population, care setting, category, title, description and period, with which role, authority, preference and limits?", "kind": "ownership", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "subject-population-care-setting-category-title-description-and-period-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to subject, population, care setting, category, title, description and period, and how is it validated or corrected?", "kind": "quality", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "subject-population-care-setting-category-title-description-and-period-data", "name": "Subject, population, care setting, category, title, description and period data", "description": "Typed data for subject, population, care setting, category, title, description and period with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013" ] } ], "artifacts": [ { "id": "subject-population-care-setting-category-title-description-and-period-record", "name": "Subject, population, care setting, category, title, description and period record", "description": "Immutable or successor-versioned evidence for subject, population, care setting, category, title, description and period.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for subject-population-care-setting-category-title-description-and-period; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013" ] } ], "inline_only_rationale": null }, { "id": "planning-responsibility-encounter-work-item-and-performed-event-distinction", "name": "Planning, responsibility, encounter, work item and performed-event distinction", "description": "Records planning, responsibility, encounter, work item and performed-event distinction as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013" ], "questions": [ { "id": "planning-responsibility-encounter-work-item-and-performed-event-distinction-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish planning, responsibility, encounter, work item and performed-event distinction?", "kind": "relationship", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "planning-responsibility-encounter-work-item-and-performed-event-distinction-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by planning, responsibility, encounter, work item and performed-event distinction, with which role, authority, preference and limits?", "kind": "measurement", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "planning-responsibility-encounter-work-item-and-performed-event-distinction-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to planning, responsibility, encounter, work item and performed-event distinction, and how is it validated or corrected?", "kind": "security", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "planning-responsibility-encounter-work-item-and-performed-event-distinction-data", "name": "Planning, responsibility, encounter, work item and performed-event distinction data", "description": "Typed data for planning, responsibility, encounter, work item and performed-event distinction with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013" ] } ], "artifacts": [ { "id": "planning-responsibility-encounter-work-item-and-performed-event-distinction-record", "name": "Planning, responsibility, encounter, work item and performed-event distinction record", "description": "Immutable or successor-versioned evidence for planning, responsibility, encounter, work item and performed-event distinction.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for planning-responsibility-encounter-work-item-and-performed-event-distinction; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-008", "SRC-012", "SRC-013" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "concerns-assessment-goals-targets-preferences-and-decisions", "name": "Concerns, assessment, goals, targets, preferences and decisions", "description": "Groups governed care context for concerns, assessment, goals, targets, preferences and decisions.", "rationale": "Care intent is interpretable only when concerns, evidence, desired outcomes, priorities and person preferences remain attributable and separately governed.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-018" ], "layers": [ { "id": "conditions-concerns-reasons-assessment-and-supporting-evidence", "name": "Conditions, concerns, reasons, assessment and supporting evidence", "description": "Groups source-qualified care context for conditions, concerns, reasons, assessment and supporting evidence.", "source_refs": [ "SRC-001", "SRC-002", "SRC-009", "SRC-010", "SRC-011", "SRC-018" ], "findings": [ { "id": "condition-problem-concern-reason-and-health-need-references", "name": "Condition, problem, concern, reason and health-need references", "description": "Records condition, problem, concern, reason and health-need references as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-009", "SRC-010", "SRC-011", "SRC-018" ], "questions": [ { "id": "condition-problem-concern-reason-and-health-need-references-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish condition, problem, concern, reason and health-need references?", "kind": "relationship", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "condition-problem-concern-reason-and-health-need-references-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by condition, problem, concern, reason and health-need references, with which role, authority, preference and limits?", "kind": "exception", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "condition-problem-concern-reason-and-health-need-references-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to condition, problem, concern, reason and health-need references, and how is it validated or corrected?", "kind": "retention", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "condition-problem-concern-reason-and-health-need-references-data", "name": "Condition, problem, concern, reason and health-need references data", "description": "Typed data for condition, problem, concern, reason and health-need references with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-009", "SRC-010", "SRC-011", "SRC-018" ] } ], "artifacts": [ { "id": "condition-problem-concern-reason-and-health-need-references-record", "name": "Condition, problem, concern, reason and health-need references record", "description": "Immutable or successor-versioned evidence for condition, problem, concern, reason and health-need references.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for condition-problem-concern-reason-and-health-need-references; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-009", "SRC-010", "SRC-011", "SRC-018" ] } ], "inline_only_rationale": null }, { "id": "clinical-impression-baseline-risk-priority-and-supporting-information", "name": "Clinical impression, baseline, risk, priority and supporting information", "description": "Records clinical impression, baseline, risk, priority and supporting information as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-009", "SRC-010", "SRC-011", "SRC-018" ], "questions": [ { "id": "clinical-impression-baseline-risk-priority-and-supporting-information-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish clinical impression, baseline, risk, priority and supporting information?", "kind": "evidence", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "clinical-impression-baseline-risk-priority-and-supporting-information-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by clinical impression, baseline, risk, priority and supporting information, with which role, authority, preference and limits?", "kind": "provenance", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "clinical-impression-baseline-risk-priority-and-supporting-information-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to clinical impression, baseline, risk, priority and supporting information, and how is it validated or corrected?", "kind": "interoperability", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "clinical-impression-baseline-risk-priority-and-supporting-information-data", "name": "Clinical impression, baseline, risk, priority and supporting information data", "description": "Typed data for clinical impression, baseline, risk, priority and supporting information with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-009", "SRC-010", "SRC-011", "SRC-018" ] } ], "artifacts": [ { "id": "clinical-impression-baseline-risk-priority-and-supporting-information-record", "name": "Clinical impression, baseline, risk, priority and supporting information record", "description": "Immutable or successor-versioned evidence for clinical impression, baseline, risk, priority and supporting information.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for clinical-impression-baseline-risk-priority-and-supporting-information; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-009", "SRC-010", "SRC-011", "SRC-018" ] } ], "inline_only_rationale": null } ] }, { "id": "goals-targets-outcomes-preferences-and-shared-decisions", "name": "Goals, targets, outcomes, preferences and shared decisions", "description": "Groups source-qualified care context for goals, targets, outcomes, preferences and shared decisions.", "source_refs": [ "SRC-003", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015" ], "findings": [ { "id": "goal-identity-description-priority-lifecycle-achievement-source-and-addresses", "name": "Goal identity, description, priority, lifecycle, achievement, source and addresses", "description": "Records goal identity, description, priority, lifecycle, achievement, source and addresses as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-003", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015" ], "questions": [ { "id": "goal-identity-description-priority-lifecycle-achievement-source-and-addresses-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish goal identity, description, priority, lifecycle, achievement, source and addresses?", "kind": "lifecycle", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "goal-identity-description-priority-lifecycle-achievement-source-and-addresses-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by goal identity, description, priority, lifecycle, achievement, source and addresses, with which role, authority, preference and limits?", "kind": "process", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "goal-identity-description-priority-lifecycle-achievement-source-and-addresses-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to goal identity, description, priority, lifecycle, achievement, source and addresses, and how is it validated or corrected?", "kind": "decision", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "goal-identity-description-priority-lifecycle-achievement-source-and-addresses-data", "name": "Goal identity, description, priority, lifecycle, achievement, source and addresses data", "description": "Typed data for goal identity, description, priority, lifecycle, achievement, source and addresses with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-003", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "goal-identity-description-priority-lifecycle-achievement-source-and-addresses-record", "name": "Goal identity, description, priority, lifecycle, achievement, source and addresses record", "description": "Immutable or successor-versioned evidence for goal identity, description, priority, lifecycle, achievement, source and addresses.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for goal-identity-description-priority-lifecycle-achievement-source-and-addresses; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-003", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "target-measure-value-timeframe-outcome-preference-and-decision-rationale", "name": "Target measure, value, timeframe, outcome, preference and decision rationale", "description": "Records target measure, value, timeframe, outcome, preference and decision rationale as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-003", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015" ], "questions": [ { "id": "target-measure-value-timeframe-outcome-preference-and-decision-rationale-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish target measure, value, timeframe, outcome, preference and decision rationale?", "kind": "measurement", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "target-measure-value-timeframe-outcome-preference-and-decision-rationale-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by target measure, value, timeframe, outcome, preference and decision rationale, with which role, authority, preference and limits?", "kind": "validation", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "target-measure-value-timeframe-outcome-preference-and-decision-rationale-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to target measure, value, timeframe, outcome, preference and decision rationale, and how is it validated or corrected?", "kind": "state", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "target-measure-value-timeframe-outcome-preference-and-decision-rationale-data", "name": "Target measure, value, timeframe, outcome, preference and decision rationale data", "description": "Typed data for target measure, value, timeframe, outcome, preference and decision rationale with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-003", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "target-measure-value-timeframe-outcome-preference-and-decision-rationale-record", "name": "Target measure, value, timeframe, outcome, preference and decision rationale record", "description": "Immutable or successor-versioned evidence for target measure, value, timeframe, outcome, preference and decision rationale.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for target-measure-value-timeframe-outcome-preference-and-decision-rationale; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-003", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "participants-responsibility-authority-and-person-centred-governance", "name": "Participants, responsibility, authority and person-centred governance", "description": "Groups governed care context for participants, responsibility, authority and person-centred governance.", "rationale": "Named roles, responsibility periods, participation and decision authority prevent a plan from becoming an unauthored list of intentions.", "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ], "layers": [ { "id": "care-team-participants-roles-periods-and-responsibilities", "name": "Care-team participants, roles, periods and responsibilities", "description": "Groups source-qualified care context for care-team participants, roles, periods and responsibilities.", "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ], "findings": [ { "id": "care-team-member-role-on-behalf-of-contact-availability-and-period", "name": "Care-team member, role, on-behalf-of, contact, availability and period", "description": "Records care-team member, role, on-behalf-of, contact, availability and period as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ], "questions": [ { "id": "care-team-member-role-on-behalf-of-contact-availability-and-period-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish care-team member, role, on-behalf-of, contact, availability and period?", "kind": "ownership", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "care-team-member-role-on-behalf-of-contact-availability-and-period-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by care-team member, role, on-behalf-of, contact, availability and period, with which role, authority, preference and limits?", "kind": "privacy", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "care-team-member-role-on-behalf-of-contact-availability-and-period-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to care-team member, role, on-behalf-of, contact, availability and period, and how is it validated or corrected?", "kind": "identity", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "care-team-member-role-on-behalf-of-contact-availability-and-period-data", "name": "Care-team member, role, on-behalf-of, contact, availability and period data", "description": "Typed data for care-team member, role, on-behalf-of, contact, availability and period with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ] } ], "artifacts": [ { "id": "care-team-member-role-on-behalf-of-contact-availability-and-period-record", "name": "Care-team member, role, on-behalf-of, contact, availability and period record", "description": "Immutable or successor-versioned evidence for care-team member, role, on-behalf-of, contact, availability and period.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for care-team-member-role-on-behalf-of-contact-availability-and-period; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "care-manager-managing-organization-custodian-author-contributor-and-reviewer", "name": "Care manager, managing organization, custodian, author, contributor and reviewer", "description": "Records care manager, managing organization, custodian, author, contributor and reviewer as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ], "questions": [ { "id": "care-manager-managing-organization-custodian-author-contributor-and-reviewer-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish care manager, managing organization, custodian, author, contributor and reviewer?", "kind": "authority", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "care-manager-managing-organization-custodian-author-contributor-and-reviewer-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by care manager, managing organization, custodian, author, contributor and reviewer, with which role, authority, preference and limits?", "kind": "lifecycle", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "care-manager-managing-organization-custodian-author-contributor-and-reviewer-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to care manager, managing organization, custodian, author, contributor and reviewer, and how is it validated or corrected?", "kind": "classification", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "care-manager-managing-organization-custodian-author-contributor-and-reviewer-data", "name": "Care manager, managing organization, custodian, author, contributor and reviewer data", "description": "Typed data for care manager, managing organization, custodian, author, contributor and reviewer with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ] } ], "artifacts": [ { "id": "care-manager-managing-organization-custodian-author-contributor-and-reviewer-record", "name": "Care manager, managing organization, custodian, author, contributor and reviewer record", "description": "Immutable or successor-versioned evidence for care manager, managing organization, custodian, author, contributor and reviewer.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for care-manager-managing-organization-custodian-author-contributor-and-reviewer; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ] } ], "inline_only_rationale": null } ] }, { "id": "subject-participation-consent-preferences-access-and-exceptions", "name": "Subject participation, consent, preferences, access and exceptions", "description": "Groups source-qualified care context for subject participation, consent, preferences, access and exceptions.", "source_refs": [ "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ], "findings": [ { "id": "subject-representative-participation-shared-decision-and-disagreement", "name": "Subject, representative, participation, shared decision and disagreement", "description": "Records subject, representative, participation, shared decision and disagreement as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ], "questions": [ { "id": "subject-representative-participation-shared-decision-and-disagreement-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish subject, representative, participation, shared decision and disagreement?", "kind": "decision", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "subject-representative-participation-shared-decision-and-disagreement-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by subject, representative, participation, shared decision and disagreement, with which role, authority, preference and limits?", "kind": "quality", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "subject-representative-participation-shared-decision-and-disagreement-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to subject, representative, participation, shared decision and disagreement, and how is it validated or corrected?", "kind": "relationship", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "subject-representative-participation-shared-decision-and-disagreement-data", "name": "Subject, representative, participation, shared decision and disagreement data", "description": "Typed data for subject, representative, participation, shared decision and disagreement with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ] } ], "artifacts": [ { "id": "subject-representative-participation-shared-decision-and-disagreement-record", "name": "Subject, representative, participation, shared decision and disagreement record", "description": "Immutable or successor-versioned evidence for subject, representative, participation, shared decision and disagreement.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for subject-representative-participation-shared-decision-and-disagreement; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ] } ], "inline_only_rationale": null }, { "id": "consent-purpose-access-scope-redaction-emergency-and-legal-exception", "name": "Consent, purpose, access scope, redaction, emergency and legal exception", "description": "Records consent, purpose, access scope, redaction, emergency and legal exception as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ], "questions": [ { "id": "consent-purpose-access-scope-redaction-emergency-and-legal-exception-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish consent, purpose, access scope, redaction, emergency and legal exception?", "kind": "privacy", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "consent-purpose-access-scope-redaction-emergency-and-legal-exception-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by consent, purpose, access scope, redaction, emergency and legal exception, with which role, authority, preference and limits?", "kind": "security", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "consent-purpose-access-scope-redaction-emergency-and-legal-exception-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to consent, purpose, access scope, redaction, emergency and legal exception, and how is it validated or corrected?", "kind": "authority", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "consent-purpose-access-scope-redaction-emergency-and-legal-exception-data", "name": "Consent, purpose, access scope, redaction, emergency and legal exception data", "description": "Typed data for consent, purpose, access scope, redaction, emergency and legal exception with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ] } ], "artifacts": [ { "id": "consent-purpose-access-scope-redaction-emergency-and-legal-exception-record", "name": "Consent, purpose, access scope, redaction, emergency and legal exception record", "description": "Immutable or successor-versioned evidence for consent, purpose, access scope, redaction, emergency and legal exception.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for consent-purpose-access-scope-redaction-emergency-and-legal-exception; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-017", "SRC-018" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "planned-activities-protocols-timing-and-coordination", "name": "Planned activities, protocols, timing and coordination", "description": "Groups governed care context for planned activities, protocols, timing and coordination.", "rationale": "The plan groups intended activity references and coordination constraints while requests, tasks and executable protocols retain independent ownership.", "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ], "layers": [ { "id": "activity-intent-request-links-definitions-and-deviations", "name": "Activity intent, request links, definitions and deviations", "description": "Groups source-qualified care context for activity intent, request links, definitions and deviations.", "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016" ], "findings": [ { "id": "planned-activity-request-reference-intent-status-owner-and-focus", "name": "Planned activity, request reference, intent, status, owner and focus", "description": "Records planned activity, request reference, intent, status, owner and focus as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016" ], "questions": [ { "id": "planned-activity-request-reference-intent-status-owner-and-focus-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish planned activity, request reference, intent, status, owner and focus?", "kind": "requirement", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "planned-activity-request-reference-intent-status-owner-and-focus-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by planned activity, request reference, intent, status, owner and focus, with which role, authority, preference and limits?", "kind": "retention", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "planned-activity-request-reference-intent-status-owner-and-focus-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to planned activity, request reference, intent, status, owner and focus, and how is it validated or corrected?", "kind": "requirement", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "planned-activity-request-reference-intent-status-owner-and-focus-data", "name": "Planned activity, request reference, intent, status, owner and focus data", "description": "Typed data for planned activity, request reference, intent, status, owner and focus with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "planned-activity-request-reference-intent-status-owner-and-focus-record", "name": "Planned activity, request reference, intent, status, owner and focus record", "description": "Immutable or successor-versioned evidence for planned activity, request reference, intent, status, owner and focus.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for planned-activity-request-reference-intent-status-owner-and-focus; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "protocol-order-set-plan-definition-instantiation-version-and-deviation", "name": "Protocol, order set, plan-definition instantiation, version and deviation", "description": "Records protocol, order set, plan-definition instantiation, version and deviation as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016" ], "questions": [ { "id": "protocol-order-set-plan-definition-instantiation-version-and-deviation-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish protocol, order set, plan-definition instantiation, version and deviation?", "kind": "provenance", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "protocol-order-set-plan-definition-instantiation-version-and-deviation-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by protocol, order set, plan-definition instantiation, version and deviation, with which role, authority, preference and limits?", "kind": "interoperability", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "protocol-order-set-plan-definition-instantiation-version-and-deviation-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to protocol, order set, plan-definition instantiation, version and deviation, and how is it validated or corrected?", "kind": "constraint", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "protocol-order-set-plan-definition-instantiation-version-and-deviation-data", "name": "Protocol, order set, plan-definition instantiation, version and deviation data", "description": "Typed data for protocol, order set, plan-definition instantiation, version and deviation with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "protocol-order-set-plan-definition-instantiation-version-and-deviation-record", "name": "Protocol, order set, plan-definition instantiation, version and deviation record", "description": "Immutable or successor-versioned evidence for protocol, order set, plan-definition instantiation, version and deviation.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for protocol-order-set-plan-definition-instantiation-version-and-deviation; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null } ] }, { "id": "timing-recurrence-dependencies-conditions-options-and-coordination", "name": "Timing, recurrence, dependencies, conditions, options and coordination", "description": "Groups source-qualified care context for timing, recurrence, dependencies, conditions, options and coordination.", "source_refs": [ "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ], "findings": [ { "id": "planned-window-schedule-recurrence-duration-deadline-and-flexibility", "name": "Planned window, schedule, recurrence, duration, deadline and flexibility", "description": "Records planned window, schedule, recurrence, duration, deadline and flexibility as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ], "questions": [ { "id": "planned-window-schedule-recurrence-duration-deadline-and-flexibility-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish planned window, schedule, recurrence, duration, deadline and flexibility?", "kind": "temporal", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "planned-window-schedule-recurrence-duration-deadline-and-flexibility-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by planned window, schedule, recurrence, duration, deadline and flexibility, with which role, authority, preference and limits?", "kind": "decision", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "planned-window-schedule-recurrence-duration-deadline-and-flexibility-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to planned window, schedule, recurrence, duration, deadline and flexibility, and how is it validated or corrected?", "kind": "event", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "planned-window-schedule-recurrence-duration-deadline-and-flexibility-data", "name": "Planned window, schedule, recurrence, duration, deadline and flexibility data", "description": "Typed data for planned window, schedule, recurrence, duration, deadline and flexibility with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ] } ], "artifacts": [ { "id": "planned-window-schedule-recurrence-duration-deadline-and-flexibility-record", "name": "Planned window, schedule, recurrence, duration, deadline and flexibility record", "description": "Immutable or successor-versioned evidence for planned window, schedule, recurrence, duration, deadline and flexibility.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for planned-window-schedule-recurrence-duration-deadline-and-flexibility; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ] } ], "inline_only_rationale": null }, { "id": "related-action-sequence-prerequisite-condition-selection-alternative-and-stop-rule", "name": "Related action, sequence, prerequisite, condition, selection, alternative and stop rule", "description": "Records related action, sequence, prerequisite, condition, selection, alternative and stop rule as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ], "questions": [ { "id": "related-action-sequence-prerequisite-condition-selection-alternative-and-stop-rule-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish related action, sequence, prerequisite, condition, selection, alternative and stop rule?", "kind": "constraint", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "related-action-sequence-prerequisite-condition-selection-alternative-and-stop-rule-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by related action, sequence, prerequisite, condition, selection, alternative and stop rule, with which role, authority, preference and limits?", "kind": "state", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "related-action-sequence-prerequisite-condition-selection-alternative-and-stop-rule-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to related action, sequence, prerequisite, condition, selection, alternative and stop rule, and how is it validated or corrected?", "kind": "temporal", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "related-action-sequence-prerequisite-condition-selection-alternative-and-stop-rule-data", "name": "Related action, sequence, prerequisite, condition, selection, alternative and stop rule data", "description": "Typed data for related action, sequence, prerequisite, condition, selection, alternative and stop rule with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ] } ], "artifacts": [ { "id": "related-action-sequence-prerequisite-condition-selection-alternative-and-stop-rule-record", "name": "Related action, sequence, prerequisite, condition, selection, alternative and stop rule record", "description": "Immutable or successor-versioned evidence for related action, sequence, prerequisite, condition, selection, alternative and stop rule.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for related-action-sequence-prerequisite-condition-selection-alternative-and-stop-rule; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-015", "SRC-016", "SRC-019" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "realization-progress-evaluation-transitions-and-closure", "name": "Realization, progress, evaluation, transitions and closure", "description": "Groups governed care context for realization, progress, evaluation, transitions and closure.", "rationale": "Observed delivery, evaluation and transfer evidence must be linked without being inferred from plan or episode status.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-007", "SRC-008", "SRC-011", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ], "layers": [ { "id": "encounters-tasks-performed-events-progress-and-goal-evaluation", "name": "Encounters, tasks, performed events, progress and goal evaluation", "description": "Groups source-qualified care context for encounters, tasks, performed events, progress and goal evaluation.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-011", "SRC-015" ], "findings": [ { "id": "encounter-task-request-and-performed-activity-reference-with-independent-state", "name": "Encounter, task, request and performed-activity reference with independent state", "description": "Records encounter, task, request and performed-activity reference with independent state as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-011", "SRC-015" ], "questions": [ { "id": "encounter-task-request-and-performed-activity-reference-with-independent-state-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish encounter, task, request and performed-activity reference with independent state?", "kind": "event", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "encounter-task-request-and-performed-activity-reference-with-independent-state-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by encounter, task, request and performed-activity reference with independent state, with which role, authority, preference and limits?", "kind": "identity", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "encounter-task-request-and-performed-activity-reference-with-independent-state-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to encounter, task, request and performed-activity reference with independent state, and how is it validated or corrected?", "kind": "composition", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "encounter-task-request-and-performed-activity-reference-with-independent-state-data", "name": "Encounter, task, request and performed-activity reference with independent state data", "description": "Typed data for encounter, task, request and performed-activity reference with independent state with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-011", "SRC-015" ] } ], "artifacts": [ { "id": "encounter-task-request-and-performed-activity-reference-with-independent-state-record", "name": "Encounter, task, request and performed-activity reference with independent state record", "description": "Immutable or successor-versioned evidence for encounter, task, request and performed-activity reference with independent state.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for encounter-task-request-and-performed-activity-reference-with-independent-state; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-011", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "progress-note-observation-goal-evaluation-outcome-variance-and-uncertainty", "name": "Progress note, observation, goal evaluation, outcome, variance and uncertainty", "description": "Records progress note, observation, goal evaluation, outcome, variance and uncertainty as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-011", "SRC-015" ], "questions": [ { "id": "progress-note-observation-goal-evaluation-outcome-variance-and-uncertainty-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish progress note, observation, goal evaluation, outcome, variance and uncertainty?", "kind": "validation", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "progress-note-observation-goal-evaluation-outcome-variance-and-uncertainty-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by progress note, observation, goal evaluation, outcome, variance and uncertainty, with which role, authority, preference and limits?", "kind": "classification", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "progress-note-observation-goal-evaluation-outcome-variance-and-uncertainty-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to progress note, observation, goal evaluation, outcome, variance and uncertainty, and how is it validated or corrected?", "kind": "evidence", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "progress-note-observation-goal-evaluation-outcome-variance-and-uncertainty-data", "name": "Progress note, observation, goal evaluation, outcome, variance and uncertainty data", "description": "Typed data for progress note, observation, goal evaluation, outcome, variance and uncertainty with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-011", "SRC-015" ] } ], "artifacts": [ { "id": "progress-note-observation-goal-evaluation-outcome-variance-and-uncertainty-record", "name": "Progress note, observation, goal evaluation, outcome, variance and uncertainty record", "description": "Immutable or successor-versioned evidence for progress note, observation, goal evaluation, outcome, variance and uncertainty.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for progress-note-observation-goal-evaluation-outcome-variance-and-uncertainty; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-011", "SRC-015" ] } ], "inline_only_rationale": null } ] }, { "id": "referral-handoff-transfer-responsibility-transition-and-closure", "name": "Referral, handoff, transfer, responsibility transition and closure", "description": "Groups source-qualified care context for referral, handoff, transfer, responsibility transition and closure.", "source_refs": [ "SRC-002", "SRC-004", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ], "findings": [ { "id": "referral-handoff-transfer-sender-receiver-acknowledgement-and-pending-work", "name": "Referral, handoff, transfer, sender, receiver, acknowledgement and pending work", "description": "Records referral, handoff, transfer, sender, receiver, acknowledgement and pending work as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-002", "SRC-004", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ], "questions": [ { "id": "referral-handoff-transfer-sender-receiver-acknowledgement-and-pending-work-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish referral, handoff, transfer, sender, receiver, acknowledgement and pending work?", "kind": "process", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "referral-handoff-transfer-sender-receiver-acknowledgement-and-pending-work-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by referral, handoff, transfer, sender, receiver, acknowledgement and pending work, with which role, authority, preference and limits?", "kind": "relationship", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "referral-handoff-transfer-sender-receiver-acknowledgement-and-pending-work-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to referral, handoff, transfer, sender, receiver, acknowledgement and pending work, and how is it validated or corrected?", "kind": "ownership", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "referral-handoff-transfer-sender-receiver-acknowledgement-and-pending-work-data", "name": "Referral, handoff, transfer, sender, receiver, acknowledgement and pending work data", "description": "Typed data for referral, handoff, transfer, sender, receiver, acknowledgement and pending work with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-002", "SRC-004", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ] } ], "artifacts": [ { "id": "referral-handoff-transfer-sender-receiver-acknowledgement-and-pending-work-record", "name": "Referral, handoff, transfer, sender, receiver, acknowledgement and pending work record", "description": "Immutable or successor-versioned evidence for referral, handoff, transfer, sender, receiver, acknowledgement and pending work.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for referral-handoff-transfer-sender-receiver-acknowledgement-and-pending-work; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-002", "SRC-004", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ] } ], "inline_only_rationale": null }, { "id": "episode-status-history-responsibility-period-closure-outcome-and-unresolved-items", "name": "Episode status history, responsibility period, closure, outcome and unresolved items", "description": "Records episode status history, responsibility period, closure, outcome and unresolved items as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-002", "SRC-004", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ], "questions": [ { "id": "episode-status-history-responsibility-period-closure-outcome-and-unresolved-items-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish episode status history, responsibility period, closure, outcome and unresolved items?", "kind": "lifecycle", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "episode-status-history-responsibility-period-closure-outcome-and-unresolved-items-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by episode status history, responsibility period, closure, outcome and unresolved items, with which role, authority, preference and limits?", "kind": "authority", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "episode-status-history-responsibility-period-closure-outcome-and-unresolved-items-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to episode status history, responsibility period, closure, outcome and unresolved items, and how is it validated or corrected?", "kind": "measurement", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "episode-status-history-responsibility-period-closure-outcome-and-unresolved-items-data", "name": "Episode status history, responsibility period, closure, outcome and unresolved items data", "description": "Typed data for episode status history, responsibility period, closure, outcome and unresolved items with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-002", "SRC-004", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ] } ], "artifacts": [ { "id": "episode-status-history-responsibility-period-closure-outcome-and-unresolved-items-record", "name": "Episode status history, responsibility period, closure, outcome and unresolved items record", "description": "Immutable or successor-versioned evidence for episode status history, responsibility period, closure, outcome and unresolved items.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for episode-status-history-responsibility-period-closure-outcome-and-unresolved-items; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-002", "SRC-004", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-015", "SRC-019" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "independent-lifecycles-correction-provenance-retention-and-projection", "name": "Independent lifecycles, correction, provenance, retention and projection", "description": "Groups governed care context for independent lifecycles, correction, provenance, retention and projection.", "rationale": "Safe agent use requires independent status axes, append-only correction, protected views and loss-aware mappings.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ], "layers": [ { "id": "plan-and-episode-status-version-change-cancellation-and-correction", "name": "Plan and episode status, version, change, cancellation and correction", "description": "Groups source-qualified care context for plan and episode status, version, change, cancellation and correction.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-018", "SRC-019" ], "findings": [ { "id": "independent-plan-episode-goal-request-task-and-activity-status-axes", "name": "Independent plan, episode, goal, request, task and activity status axes", "description": "Records independent plan, episode, goal, request, task and activity status axes as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-018", "SRC-019" ], "questions": [ { "id": "independent-plan-episode-goal-request-task-and-activity-status-axes-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish independent plan, episode, goal, request, task and activity status axes?", "kind": "state", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "independent-plan-episode-goal-request-task-and-activity-status-axes-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by independent plan, episode, goal, request, task and activity status axes, with which role, authority, preference and limits?", "kind": "requirement", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "independent-plan-episode-goal-request-task-and-activity-status-axes-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to independent plan, episode, goal, request, task and activity status axes, and how is it validated or corrected?", "kind": "exception", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "independent-plan-episode-goal-request-task-and-activity-status-axes-data", "name": "Independent plan, episode, goal, request, task and activity status axes data", "description": "Typed data for independent plan, episode, goal, request, task and activity status axes with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-018", "SRC-019" ] } ], "artifacts": [ { "id": "independent-plan-episode-goal-request-task-and-activity-status-axes-record", "name": "Independent plan, episode, goal, request, task and activity status axes record", "description": "Immutable or successor-versioned evidence for independent plan, episode, goal, request, task and activity status axes.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for independent-plan-episode-goal-request-task-and-activity-status-axes; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-018", "SRC-019" ] } ], "inline_only_rationale": null }, { "id": "amend-replace-hold-revoke-cancel-entered-in-error-supersede-and-noncascade", "name": "Amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade", "description": "Records amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-018", "SRC-019" ], "questions": [ { "id": "amend-replace-hold-revoke-cancel-entered-in-error-supersede-and-noncascade-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade?", "kind": "exception", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "amend-replace-hold-revoke-cancel-entered-in-error-supersede-and-noncascade-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade, with which role, authority, preference and limits?", "kind": "constraint", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "amend-replace-hold-revoke-cancel-entered-in-error-supersede-and-noncascade-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade, and how is it validated or corrected?", "kind": "provenance", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "amend-replace-hold-revoke-cancel-entered-in-error-supersede-and-noncascade-data", "name": "Amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade data", "description": "Typed data for amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-018", "SRC-019" ] } ], "artifacts": [ { "id": "amend-replace-hold-revoke-cancel-entered-in-error-supersede-and-noncascade-record", "name": "Amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade record", "description": "Immutable or successor-versioned evidence for amend, replace, hold, revoke, cancel, entered-in-error, supersede and non-cascade.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for amend-replace-hold-revoke-cancel-entered-in-error-supersede-and-noncascade; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-008", "SRC-018", "SRC-019" ] } ], "inline_only_rationale": null } ] }, { "id": "source-quality-privacy-retention-interoperability-and-agent-controls", "name": "Source quality, privacy, retention, interoperability and agent controls", "description": "Groups source-qualified care context for source quality, privacy, retention, interoperability and agent controls.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ], "findings": [ { "id": "source-confidence-provenance-disclosure-audit-legal-hold-retention-and-disposition", "name": "Source confidence, provenance, disclosure, audit, legal hold, retention and disposition", "description": "Records source confidence, provenance, disclosure, audit, legal hold, retention and disposition as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ], "questions": [ { "id": "source-confidence-provenance-disclosure-audit-legal-hold-retention-and-disposition-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish source confidence, provenance, disclosure, audit, legal hold, retention and disposition?", "kind": "retention", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "source-confidence-provenance-disclosure-audit-legal-hold-retention-and-disposition-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by source confidence, provenance, disclosure, audit, legal hold, retention and disposition, with which role, authority, preference and limits?", "kind": "event", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "source-confidence-provenance-disclosure-audit-legal-hold-retention-and-disposition-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to source confidence, provenance, disclosure, audit, legal hold, retention and disposition, and how is it validated or corrected?", "kind": "process", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "source-confidence-provenance-disclosure-audit-legal-hold-retention-and-disposition-data", "name": "Source confidence, provenance, disclosure, audit, legal hold, retention and disposition data", "description": "Typed data for source confidence, provenance, disclosure, audit, legal hold, retention and disposition with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ] } ], "artifacts": [ { "id": "source-confidence-provenance-disclosure-audit-legal-hold-retention-and-disposition-record", "name": "Source confidence, provenance, disclosure, audit, legal hold, retention and disposition record", "description": "Immutable or successor-versioned evidence for source confidence, provenance, disclosure, audit, legal hold, retention and disposition.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for source-confidence-provenance-disclosure-audit-legal-hold-retention-and-disposition; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ] } ], "inline_only_rationale": null }, { "id": "fhir-ihe-openehr-who-nice-projection-version-maturity-loss-and-round-trip", "name": "FHIR, IHE, openEHR, WHO and NICE projection, version, maturity, loss and round trip", "description": "Records fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip as source-qualified care-planning or episode context while preserving the distinctions among intent, responsibility, encounter, work item, performance, observation and outcome.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ], "questions": [ { "id": "fhir-ihe-openehr-who-nice-projection-version-maturity-loss-and-round-trip-q01", "text": "Which stable identities, record class, source-qualified assertions and explicit unknowns establish fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip?", "kind": "interoperability", "answer_data": [ "identifiers and class", "source-qualified assertions", "unknown and not-applicable states" ] }, { "id": "fhir-ihe-openehr-who-nice-projection-version-maturity-loss-and-round-trip-q02", "text": "Who proposed, authored, accepted, owns, performs, reviews or is affected by fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip, with which role, authority, preference and limits?", "kind": "temporal", "answer_data": [ "actors and roles", "authority and participation", "preferences, limits and exceptions" ] }, { "id": "fhir-ihe-openehr-who-nice-projection-version-maturity-loss-and-round-trip-q03", "text": "Which authored, effective, planned, scheduled, occurrence, evaluation, transition, recorded, ingested and knowledge times apply to fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip, and how is it validated or corrected?", "kind": "validation", "answer_data": [ "distinct care and record times", "validation, progress and uncertainty", "successor correction and retention" ] } ], "data_elements": [ { "id": "fhir-ihe-openehr-who-nice-projection-version-maturity-loss-and-round-trip-data", "name": "FHIR, IHE, openEHR, WHO and NICE projection, version, maturity, loss and round trip data", "description": "Typed data for fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip with constituent identity, source, authority, status, clinical time, record time, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ] } ], "artifacts": [ { "id": "fhir-ihe-openehr-who-nice-projection-version-maturity-loss-and-round-trip-record", "name": "FHIR, IHE, openEHR, WHO and NICE projection, version, maturity, loss and round trip record", "description": "Immutable or successor-versioned evidence for fhir, ihe, openehr, who and nice projection, version, maturity, loss and round trip.", "media_or_form": [ "logical care-context assertion", "plan, episode, goal, participant, activity, transition, evaluation or projection record" ], "serial": true, "identity_strategy": "Aggregate ID plus independent plan, episode, goal, participation, action, transition or assertion ID for fhir-ihe-openehr-who-nice-projection-version-maturity-loss-and-round-trip; patient, title, condition and date never identify the record alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ] } ], "inline_only_rationale": null } ] } ] } ] }, "functions": [ { "id": "register-care-context-aggregate", "name": "Register care context aggregate", "description": "Governed operation to register care context aggregate without hidden mutation or execution of external clinical masters.", "inputs": [ "source records", "subject", "profile", "steward authority" ], "outputs": [ "aggregate root and constituent slots" ], "preconditions": [ "stable identity, source, subject and boundary pass" ], "effects": [ "one aggregate links independent plan and episode records without collapsing them" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-015", "SRC-018" ] }, { "id": "create-or-revise-care-plan", "name": "Create or revise care plan", "description": "Governed operation to create or revise care plan without hidden mutation or execution of external clinical masters.", "inputs": [ "care concerns", "goals", "participants", "planned activity references" ], "outputs": [ "versioned plan record" ], "preconditions": [ "author, custodian, subject, intent, status, period and authority pass" ], "effects": [ "care intent is recorded without asserting execution or outcome" ], "source_refs": [ "SRC-001", "SRC-003", "SRC-004", "SRC-014" ] }, { "id": "open-or-track-episode", "name": "Open or track episode", "description": "Governed operation to open or track episode without hidden mutation or execution of external clinical masters.", "inputs": [ "subject", "managing organization", "care manager", "reason", "period" ], "outputs": [ "versioned episode record and status event" ], "preconditions": [ "provider responsibility, source, identity and episode boundary pass" ], "effects": [ "responsibility tracking begins or changes without creating encounters" ], "source_refs": [ "SRC-002", "SRC-012", "SRC-013" ] }, { "id": "establish-or-evaluate-goal", "name": "Establish or evaluate goal", "description": "Governed operation to establish or evaluate goal without hidden mutation or execution of external clinical masters.", "inputs": [ "desired state", "target", "priority", "source", "evidence links" ], "outputs": [ "goal or goal-evaluation assertion" ], "preconditions": [ "subject, goal identity, target semantics, evaluator and evidence pass" ], "effects": [ "desired state and observed achievement remain distinct" ], "source_refs": [ "SRC-003", "SRC-011", "SRC-014" ] }, { "id": "bind-care-team-and-responsibilities", "name": "Bind care team and responsibilities", "description": "Governed operation to bind care team and responsibilities without hidden mutation or execution of external clinical masters.", "inputs": [ "participants", "roles", "on-behalf-of", "periods", "responsibilities" ], "outputs": [ "attributable participation set" ], "preconditions": [ "identity, role, authority, availability and consent pass" ], "effects": [ "responsibility becomes explicit without changing participant masters" ], "source_refs": [ "SRC-004", "SRC-012", "SRC-014", "SRC-017" ] }, { "id": "coordinate-planned-requests", "name": "Coordinate planned requests", "description": "Governed operation to coordinate planned requests without hidden mutation or execution of external clinical masters.", "inputs": [ "activity references", "dependencies", "conditions", "timing", "options" ], "outputs": [ "coordination graph and validation report" ], "preconditions": [ "each request retains identity, intent, owner and status; dependency graph is valid" ], "effects": [ "coordination is recorded without executing requests or tasks" ], "source_refs": [ "SRC-001", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-016" ] }, { "id": "record-progress-and-link-performance", "name": "Record progress and link performance", "description": "Governed operation to record progress and link performance without hidden mutation or execution of external clinical masters.", "inputs": [ "plan", "episode", "external tasks", "encounters", "performed events", "observations" ], "outputs": [ "progress and realization links" ], "preconditions": [ "source, occurrence, performer, observation and independent status pass" ], "effects": [ "delivery evidence is linked without being inferred from plan status" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-007", "SRC-011", "SRC-015" ] }, { "id": "handoff-transfer-or-close-care-context", "name": "Handoff, transfer or close care context", "description": "Governed operation to handoff, transfer or close care context without hidden mutation or execution of external clinical masters.", "inputs": [ "current responsibility", "receiver", "pending work", "communication evidence", "closure reason" ], "outputs": [ "transition, acknowledgement or closure event" ], "preconditions": [ "authority, continuity, unresolved items and receiving scope pass" ], "effects": [ "responsibility and status change without cascading into referenced records" ], "source_refs": [ "SRC-002", "SRC-004", "SRC-012", "SRC-013", "SRC-015" ] }, { "id": "correct-hold-cancel-or-supersede", "name": "Correct, hold, cancel or supersede", "description": "Governed operation to correct, hold, cancel or supersede without hidden mutation or execution of external clinical masters.", "inputs": [ "target constituent", "reason", "authority", "expected revision" ], "outputs": [ "append-only transition or successor" ], "preconditions": [ "constituent-specific transition, provenance and non-cascade impact pass" ], "effects": [ "history remains visible and consumers can resolve the current head" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-007", "SRC-018" ] }, { "id": "project-retain-disclose-and-audit", "name": "Project, retain, disclose and audit", "description": "Governed operation to project, retain, disclose and audit without hidden mutation or execution of external clinical masters.", "inputs": [ "aggregate", "target profile", "access and retention policy" ], "outputs": [ "projection, disclosure, tombstone or disposition event" ], "preconditions": [ "mapping versions, maturity, loss, privacy, hold and idempotency pass" ], "effects": [ "context stays protected, reconstructable and explicit about loss" ], "source_refs": [ "SRC-015", "SRC-016", "SRC-017", "SRC-018", "SRC-019" ] } ], "composition": [ { "target": "WM-LIV-021 Disease / Condition", "relation": "REFERENCE", "purpose": "Record the candidate condition relation as clinical goal context without approving the edge or copying condition lifecycle.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-010" ] }, { "target": "WM-ACT-047 Medical Procedure", "relation": "REFERENCE", "purpose": "Record intended or performed procedure references while the candidate containment edge and all cascade semantics remain deferred.", "required": false, "source_refs": [ "SRC-001", "SRC-007", "SRC-008" ] }, { "target": "WM-ACT-048 Medication Order / Administration", "relation": "REFERENCE", "purpose": "Record medication request and administration references while the candidate containment edge and all medication lifecycles remain deferred.", "required": false, "source_refs": [ "SRC-001", "SRC-007", "SRC-008" ] }, { "target": "Patient, Practitioner, Organization, Condition, Observation, Encounter, Consent, CareTeam, Goal, Request, Task, Appointment, Communication, AdverseEvent, Provenance, Audit and Record models", "relation": "REFERENCE", "purpose": "Resolve authoritative subjects, actors, clinical assertions, work, evidence, communication and governance without copying their lifecycles.", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-007", "SRC-009", "SRC-010", "SRC-011", "SRC-017", "SRC-018" ] }, { "target": "FHIR R5, IHE Dynamic Care Planning, openEHR Task Planning, WHO continuity guidance and NICE NG197", "relation": "ALIGN", "purpose": "Project version-pinned clinical, continuity, shared-decision and workflow views with maturity, retirement, jurisdiction and information-loss declarations.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "serviceLayers": { "dimension": { "owner_package_requirements": [ "Dimension owner and care-governance mandate", "Patient, practitioner, organization, condition, observation, encounter, consent, plan, episode, goal, care-team, request, task, performed-event, communication, provenance, audit and record registries", "Approved clinical, terminology, measurement, workflow, shared-decision, transition, privacy, retention and interoperability profiles", "Jurisdiction, organization, setting, specialty, subject-participation and agent-operation policies" ], "namespace_guidance": "Mint aggregate, plan, episode, goal, participant-role, coordination, progress, evaluation, transition, correction, disclosure and event IDs; preserve every authoritative source-system and clinical identifier.", "registry_links": [ "https://ver.cy/models/", "https://ver.cy/model-agent-protocol.md" ] }, "canon_and_patch": { "canonicalization_rules": [ "Canonicalize each plan and episode by authoritative source-system identifier, source organization and constituent kind; never by patient, condition, title or date alone.", "Keep planning, provider responsibility, encounter, goal, request authorization, task execution, performed activity, observation and clinical outcome distinct." ], "patch_rules": [ "Extensions declare jurisdiction, setting, specialty, terminology, workflow, consent, privacy, retention and interoperability effects.", "Released plan, episode, goal, participation, coordination, transition and evaluation records are immutable; corrections create linked successors.", "Never silently change subject, concern, goal, target, preference, participant, authority, activity, dependency, period, status, outcome, access or provenance." ], "compatibility_rules": [ "Ignore additive fields only when identity, constituent kind, subject, responsibility, intent, status, time, authority, evidence and provenance survive.", "Every projection pins profile, terminology and source versions and declares information loss and standards maturity." ] }, "artifact_rules": { "identity_priority": [ "Authoritative master-system identifier for each care plan, episode, goal, participant assertion or transition, qualified by source organization and record kind.", "Governed globally resolvable care-context record IRI.", "Dimension UUID when neither preceding identifier exists." ], "timestamp_rule": "Use RFC 3339 timestamps with seconds and explicit offset or Z; distinguish authored, effective, planned, scheduled, occurrence, evaluation, handoff, transition, recorded, ingested and knowledge times whenever they differ.", "serial_naming_rule": "Use {aggregate-id}--{plan-episode-goal-action-transition-or-assertion-id}--{artifact-kind}--{revision-id}.", "integrity_rule": "Store digest, media type, constituent kind, subject binding, source and profile versions, actor, event and knowledge times, status, access marking and provenance." }, "policies": [ "The aggregate does not own Patient, Practitioner, Organization, Condition, Observation, Encounter, Consent, PlanDefinition, Request, Task, Appointment, Procedure, Medication, Communication, AdverseEvent, Provenance, Audit or Record masters.", "Plan, episode, goal, request, task, encounter, performed event, observation and outcome remain separate assertions with independent states and times.", "Completed plan or episode status never proves that every activity occurred, every goal was achieved, care was effective or no harm occurred.", "Agents cannot diagnose, authorize care, change treatment, assign responsibility, execute clinical work, infer success, disclose protected data or dispose records outside explicit clinical and policy authority." ], "crud": { "read": [ "Resolve purpose, aggregate profile, plan and episode identities, subject, concerns, goals, participants, activity references, responsibilities, progress, transitions, lineage, holds and projection loss." ], "create": [ "Bind stable aggregate and constituent identity, source, subject, responsible authority, record kind, status and effective time before recording care intent or responsibility." ], "update": [ "Append successor plan, episode, goal, participation, activity, progress, evaluation, handoff, closure and correction events with reason, authority, expected revision, event time and knowledge time." ], "delete": [ "Apply clinical-record, continuity, privacy, legal-hold and adopting-Dimension retention policy; retire or tombstone only the aggregate or named constituent without cascading to Patient, Condition, Encounter, Request, Task, Procedure, Medication, Observation or other masters, and let the external records policy execute physical disposition." ] }, "roles": [ { "name": "Care context aggregate steward", "responsibilities": [ "Own aggregate boundary, namespace, composition and quality rules." ] }, { "name": "Plan author or custodian", "responsibilities": [ "Own care-plan intent, concerns, goals, participants, activity references and revision basis within authority." ] }, { "name": "Episode manager or managing organization", "responsibilities": [ "Own provider-responsibility periods, episode status and transfer evidence." ] }, { "name": "Subject or authorized representative", "responsibilities": [ "Contribute goals, preferences, decisions, disagreement and consent within applicable capacity and policy." ] }, { "name": "Care-team participant", "responsibilities": [ "Own attributable role, availability, acknowledgement and progress contributions within scope." ] }, { "name": "Clinical reviewer", "responsibilities": [ "Review concerns, goals, targets, progress, variance and closure evidence without inventing outcomes." ] }, { "name": "Interoperability steward", "responsibilities": [ "Own versioned FHIR, IHE and other projections with maturity and loss declarations." ] }, { "name": "Privacy, records and assurance steward", "responsibilities": [ "Own protected views, disclosures, holds, retention and auditability." ] } ], "access": { "default_rule": "Deny care-plan, episode and related clinical context unless a purpose-bound policy permits the minimum necessary view.", "scopes": [ "bundle", "layer", "finding", "artifact" ], "exceptions": [ "Declared subject, representative, care team, emergency, public-health, research, regulator, court or legally authorized access must cite authority, scope, purpose and time limit where applicable and must be logged." ], "audit_requirements": [ "Log actor, agent, role, purpose, aggregate and constituent, operation, authority, policy, RFC 3339 time, affected fields, source revision and outcome without duplicating unnecessary clinical content." ] }, "agents_bootstrap": { "filename": "AGENTS.md", "required_fields": [ "Name", "Type", "Specification URL", "Storage type URL", "Interface URL", "Processes URL" ], "read_order": [ "Read Dimension clinical, shared-decision, scope-of-practice, consent, privacy, access, correction, records and agent policies.", "Read this aggregate and linked patient, condition, observation, encounter, consent, goal, care-team, request, task, procedure, medication, communication, provenance, audit and record models before mutation." ] } }, "coverage": { "claim": "WM-ACT-049 covers a source-qualified care-context aggregate that composes but does not collapse a CarePlan planning record and an EpisodeOfCare responsibility-tracking record. Goals, team participation, planned requests, tasks, encounters, performed activities, observations and transitions retain independent identities, states and times. Specialty profiles, jurisdiction rules, all three candidate registry relations, release-pinned mapping tests and independent external review remain deferred.", "confidence": "medium", "checklist": [ { "dimension": "identity", "status": "covered", "notes": "Identity is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "classification and definition", "status": "covered", "notes": "Classification and definition is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "direct properties", "status": "covered", "notes": "Direct properties is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "recognition and observation", "status": "covered", "notes": "Recognition and observation is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "capabilities and possible actions", "status": "covered", "notes": "Capabilities and possible actions is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "composition", "status": "covered", "notes": "Composition is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "lifecycle", "status": "covered", "notes": "Lifecycle is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "relationships", "status": "covered", "notes": "Relationships is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "temporal", "status": "covered", "notes": "Temporal is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "spatial", "status": "covered", "notes": "Spatial is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "provenance", "status": "covered", "notes": "Provenance is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "ownership and stewardship", "status": "covered", "notes": "Ownership and stewardship is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "validation and quality", "status": "covered", "notes": "Validation and quality is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "access and privacy", "status": "covered", "notes": "Access and privacy is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "retention and deletion", "status": "covered", "notes": "Retention and deletion is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." }, { "dimension": "interoperability", "status": "covered", "notes": "Interoperability is explicit; specialty, jurisdiction, institution, candidate relations and release-pinned validation remain held where applicable." } ], "known_omissions": [ "Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.", "WM-ACT-049 REFERENCE WM-LIV-021 and CONTAINS WM-ACT-047 and WM-ACT-048 are candidate metadata and not approved composition edges.", "Oncology, mental health, maternity, pediatric, geriatric, rehabilitation, palliative, public-health, social-care, veterinary and research planning require specialty profiles.", "FHIR R5 planning resources are Trial Use at varied maturity; IHE DCP is an implementation profile and openEHR Task Planning Release-1.7.0 is retired, so mappings require release-pinned testing." ], "conflicts": [ "A care plan is planning, while an episode tracks provider responsibility and an encounter records an activity; they are not interchangeable.", "Plan, goal, request, task, performed event and observation statuses are independent and cannot be silently synchronized.", "Completed plan or episode status does not prove activity completion, goal achievement, clinical effectiveness, continuity or absence of harm." ], "regional_assumptions": [ "Care authority, capacity, guardianship, consent, scope of practice, assignment, transfer, reporting, retention and disclosure depend on jurisdiction and setting.", "NICE NG197 is an England and Wales guideline and IHE DCP is an interoperability profile, not universal clinical or legal policy.", "Local care pathways, terminologies, role codes, responsibility rules, availability and escalation practices require versioned organization profiles." ], "adversarial_checks": [ "Reject an aggregate or constituent without stable identity, record kind, source, subject, responsible authority, status, effective time and lineage head.", "Reject a care plan represented as performed care, episode represented as encounter, goal represented as observation, or completed represented as successful.", "Reject activity coordination that loses request, task or performed-event identity, intent, owner, status, time, dependency or source.", "Reject transfer or closure that loses pending work, unresolved goals, sender, receiver, acknowledgement, responsibility period or communication evidence.", "Reject autonomous diagnosis, treatment authorization, assignment, execution, clinical inference, disclosure or disposition outside explicit authority." ] }, "researchAdjudication": { "providerMode": "single-provider-waiver", "activeProviders": [ "codex" ], "waivedProviders": [ "claude", "grok" ], "providerPolicy": { "contract_version": "1.0.0", "mode": "single-provider-waiver", "effective_at": "2026-09-06T00:00:00Z", "scope": "Canonical single-stream subject-model research after the six-workstream consolidation", "active_providers": [ "codex" ], "waived_providers": [ { "provider": "claude", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "Claude produced no result on prior 1800-second and 900-second attempts and again timed out on bounded 600-second Sonnet and 300-second Haiku passes. The owner prioritized completion over provider availability." }, { "provider": "grok", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "The repository owner authorized completion without Grok when Grok is unavailable, slow or schema-invalid. Grok may still be attempted as a bounded supplemental reviewer, but its failure never blocks a valid Claude plus no-tools result." } ], "review_rule": "Codex may complete source-grounded fallback research after bounded Claude and Grok attempts fail. It requires a separate no-tools adversarial audit and remains reviewable-draft with a visible absence-of-external-review hold.", "supplemental_provider_attempts": [ { "provider": "claude", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." }, { "provider": "grok", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." } ] }, "boundaryDecision": { "entry_kind": "aggregate", "status": "accepted", "rationale": "The slash-labelled registry subject spans two separately identifiable but operationally related records: a care plan for intention and coordination and an episode for provider responsibility over time. Aggregate is more accurate than event or entity, while each constituent retains its own identity and lifecycle. The frozen record_plane world-model and catalogue entry_kind standalone-mm are separate axes from this subject-schema decision." }, "decisions": [ { "concept": "CarePlan and EpisodeOfCare separation", "disposition": "accepted", "rationale": "FHIR defines planning and provider responsibility tracking as distinct resources and explicitly distinguishes both from Encounter activity. The aggregate composes them without flattening status, time or authority." }, { "concept": "Goal, concern, observation and outcome separation", "disposition": "accepted", "rationale": "Goals describe desired states, conditions describe concerns and observations provide evaluation evidence. Achievement and outcome remain attributable assertions rather than consequences inferred from plan completion." }, { "concept": "Care team, plan authorship and episode responsibility", "disposition": "accepted", "rationale": "Care-team participation, plan authorship or custody, care management and managing-organization responsibility are different role bindings with their own scope and effective periods." }, { "concept": "Request, task and performed-event ownership", "disposition": "accepted-external", "rationale": "A plan may group intended request references and coordination constraints, but authorization, task execution, encounters and performed clinical events remain external masters with independent state." }, { "concept": "Protocols, dependencies and workflow execution", "disposition": "accepted-with-profile-hold", "rationale": "PlanDefinition, RequestOrchestration and openEHR materials support versioned protocol links and action dependencies, but executable orchestration, clinical decision support and institutional workflow remain external and profile-specific." }, { "concept": "Continuity, handoff and shared decisions", "disposition": "accepted", "rationale": "WHO, NICE and IHE sources support person-centred participation, informational continuity, responsibility transfer, pending-work communication and acknowledgement without creating a universal clinical policy." }, { "concept": "Candidate WM-LIV-021, WM-ACT-047 and WM-ACT-048 relations", "disposition": "deferred", "rationale": "The relation ledger marks all three edges candidate. The specification may carry typed references but may not publish containment, lifecycle ownership or cascade behavior as approved." }, { "concept": "Standards maturity and retired workflow source", "disposition": "accepted-with-validation-hold", "rationale": "Most FHIR R5 planning resources are Trial Use at varied maturity, IHE DCP is an implementation profile and openEHR Task Planning Release-1.7.0 is retired. Every projection must pin version, status and information loss." }, { "concept": "Single-provider waiver and no-tools audit", "disposition": "accepted-with-mandatory-hold", "rationale": "One Claude Sonnet and one Grok 4.6 research attempt each timed out after 120 seconds. Codex audited the frozen validated result and comparison locally without tools or new research facts. Confidence remains medium and assurance remains reviewable-draft." } ], "publicationHolds": [ "Absence-of-external-review hold: one Claude Sonnet and one Grok 4.6 research attempt for WM-ACT-049 each timed out after 120 seconds. No external research result was admitted.", "Registry edge approval hold: WM-ACT-049 REFERENCE WM-LIV-021 and CONTAINS WM-ACT-047 and WM-ACT-048 remain candidate metadata and create no cascade semantics.", "Clinical-profile hold: oncology, mental health, maternity, pediatric, geriatric, rehabilitation, palliative, public-health, social-care, veterinary and research planning need specialty rules.", "Jurisdiction and institution hold: capacity, guardianship, consent, care authority, scope of practice, assignment, transfer, escalation, reporting, retention and disclosure require applicable profiles.", "Interoperability hold: FHIR maturity varies, IHE DCP is an implementation profile and openEHR Task Planning is retired; all mappings require release-pinned tests, loss declarations and clinical validation.", "Aggregate-boundary hold: adopters must preserve independent plan and episode identities and may not treat the slash-labelled catalogue name as one undifferentiated lifecycle.", "Independent external review was explicitly waived by the repository owner; this codex-only result remains a reviewable draft." ], "deferredResearch": [ "Approve or reject the three candidate relation-ledger edges and define cardinality, membership, ownership and non-cascade semantics.", "Create specialty profiles for oncology, mental health, maternity, pediatric, geriatric, rehabilitation, palliative, public-health, social-care, veterinary and research care contexts.", "Create jurisdiction and institution profiles for capacity, consent, care authority, roles, assignment, transfer, escalation, correction, retention and access.", "Test release-pinned FHIR, IHE DCP and any successor workflow mappings with round-trip, maturity and information-loss evidence.", "Obtain supplemental independent external review and resolve any material challenge before canonical promotion." ] }, "statistics": { "sources": 19, "bundles": 6, "layers": 12, "findings": 24, "questions": 72, "artifacts": 24, "functions": 10 } }