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Health records
Health informatics resources including concepts concerning the structure of health records
professional health record
health record held under the responsibility of one care provider and maintained by care professionals

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

professional health record

health record held under the responsibility of one care provider and maintained by care professionals

EXAMPLE 1 Health records held at their surgery or at a health centre by a GP, by a medical specialist, by a nurse, in a hospital department at a patient's bedside, by a care team in an integrated clinical network, by a dentist.

Note 1 to entry: The responsible care provider may allow the subject of care to access and/or offer contributions to the professional health record

Table 1. Specializations / Generalizations of **professional health record**
Specialization of			Generalization of
health record

Table 2. Associations of **professional health record**
Association from		Association name		Association to
1..*	mandated period of care	documented in		0..*	professional health record
1..*	care information for import	imported into		1..1	professional health record
0..*	care professional	maintains		1..*	professional health record

professional health recordUML Representation — Figure 1. professional health record (UML Representation)