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draft Template  Vital Signs Observation (lrtp)

Id 2.16.756.5.30.1.127.10.4.37 Effective Date 2017‑08‑14
Status draft Draft Version Label 2017
Name VitalSignsObservation Display Name Vital Signs Observation (lrtp)
Description Structured notation of a measured value resp. an observation of a single vital sign (such as body height, weight, blood pressure).
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 3 templates
Used by as Name Version
2.16.756.5.30.1.127.10.4.36 Containment draft Vital Signs Organizer Entry (lrtp) (2017) 2017‑08‑14
2.16.756.5.30.1.127.10.3.13 link draft Coded Vital Signs Section (lrtp) (2017) 2017‑08‑14
2.16.756.5.30.1.127.10.1.3 link draft Laborbefund Transplantationsprozesss 2017‑08‑14
Uses as Name Version
2.16.756.5.30.1.1.10.9.14 Include active Narrative Text Reference (2017) DYNAMIC
2.16.756.5.30.1.127.10.4.35 Include draft Check Properties DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment active IHE Comment Entry (2014) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.4.21 (2017‑03‑24 16:48:39)
Specialization: template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.13 (2016‑09‑26 08:43:40)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.756.5.30.1.1.10.4.21"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>  <templateId root="2.16.840.1.113883.10.20.1.31"/>  <id root="3B9A88CF-E868-490B-B0BF-DA25E7D2F9FA"/>  <code code="3137-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#o1"/>  </text>  <statusCode code="completed"/>  <effectiveTime value="20081118"/>  <value xsi:type="PQ" value="178" unit="cm"/>  <interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>  <methodCode nullFlavor="NA"/>  <targetSiteCode nullFlavor="NA"/></observation>
Item DT Card Conf Description Label
hl7:observation
 (Vitdotsion)
@classCode
 cs 1 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M (Vitdotsion)
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.21
hl7:templateId
 II 1 … 1 M (Vitdotsion)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:templateId
 II 1 … 1 M (Vitdotsion)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13.2
hl7:templateId
 II 1 … 1 M (Vitdotsion)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.31
hl7:id
 II 1 … 1 M An ID for this item CAN be filled for traceability. (Vitdotsion)
@extension
 st 1 … 1 R MUST contain the ID itself. The ID MUST be unique within the system that issued the ID.
@root
 uid 1 … 1 R MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.
hl7:code
 CD 1 … 1 R (Vitdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.5 Vital Signs Observation (DYNAMIC)
Included 1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
The reference to the text in the narrative section of the section MUST be specified.
hl7:text
 ED 1 … 1 M CDA‑CH V2
hl7:reference
 TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
 1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
hl7:statusCode
 CS 1 … 1 M The status 'completed' indicates that the observation is final. (Vitdotsion)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)
hl7:effectiveTime
 IVL_TS.CH.TZ NP
(de-CH) Es gilt die effectiveTime des organizer.
(Vitdotsion)
hl7:value
 ANY 1 … 1 R According to table in [IHE PCC TF-2], 6.3.4.22.3 (Vitdotsion)
hl7:interpretationCode
 CE 0 … * R (Vitdotsion)
hl7:methodCode
 CE 0 … * R (Vitdotsion)
hl7:targetSiteCode
 CD 0 … * R (Vitdotsion)
Included from 2.16.756.5.30.1.127.10.4.35 Check Properties (DYNAMIC)
  Variable let Name ap  
  Value doc('include/cs-2.16.756.5.30.1.127.77.6.5.1-DYNAMIC.xml')  
  Variable let Name apunits  
  Value $ap//concept[property/code[@value='unit']]  
  Variable let Name apDataTypes  
  Value $ap//concept[property/code[@value='dataType']]  
  Variable let Name apObservationValuePresent  
  Value $ap//concept[property/code[@value='observationValuePresent']]  
  Variable let Name apInterpretationCodePOSNEGIND  
  Value $ap//concept[property/code[@value='interpretationCodePOSNEGIND']]  
  Variable let Name apsection  
  Value $ap//concept[property/code[@value='specialtySection']]  
  Variable let Name oc  
  Value hl7:code/@code  
  Variable let Name ovu  
  Value hl7:value/@unit  
  Variable let Name dc  
  Value $apunits[code/@value=$oc]/property[code/@value='unit']/valueCode/@value  
  Schematron assert role red error  
  test string-length($ovu)=0 or count($apunits[code/@value=$oc])=0 or count($dc)=0 or $ovu=$dc  
  Message Observations with code <value-of select="$oc"/> shall have unit(s) <value-of select="$dc"/>.  
  Variable let Name osectioncode  
  Value ancestor::hl7:section/hl7:code/@code  
  Variable let Name dc  
  Value $apsection[code/@value=$oc]/property[code/@value='specialtySection']/valueCode/@value  
  Variable let Name dn  
  Value $apsection[code/@value=$oc]/property[code/@value='specialtySectionName']/valueString/@value  
  Schematron assert role red error  
  test string-length($osectioncode)=0 or string-length($dc)=0 or $osectioncode = $dc  
  Message Observations with code <value-of select="$oc"/> shall appear within a section with code <value-of select="$dc"/> <value-of select="$dn"/>, found <value-of select="$osectioncode"/>.  
  Variable let Name apDataTypes  
  Value $ap//concept[property/code[@value='dataType']]  
  Variable let Name dtr  
  Value $apDataTypes[code/@value=$oc]/property[code/@value='dataType']/valueCode/@value  
  Schematron assert role red error  
  test string-length($dtr)=0 or hl7:value[@xsi:type=$dtr]  
  Message Datatype of the value element (xsi:type) shall be <value-of select="$dtr"/>  
  Variable let Name apObservationValuePresent  
  Value $ap//concept[property/code[@value='observationValuePresent']]  
  Variable let Name vpre  
  Value $apObservationValuePresent[code/@value=$oc]/property[code/@value='observationValuePresent']/valueBoolean/@value  
  Schematron assert role red error  
  test string-length($vpre)=0 or $vpre='false' or hl7:value  
  Message Observations with code <value-of select="$oc"/> shall have a value element.  
  Schematron assert role red error  
  test string-length($vpre)=0 or $vpre='true' or not(hl7:value)  
  Message Observations with code <value-of select="$oc"/> shall not have a value element.  
  Variable let Name apInterpretationCodePOSNEGIND  
  Value $ap//concept[property/code[@value='interpretationCodePOSNEGIND']]  
  Variable let Name icd  
  Value $apInterpretationCodePOSNEGIND[code/@value=$oc]/property[code/@value='interpretationCodePOSNEGIND']/valueBoolean/@value  
  Schematron assert role red error  
  test string-length($icd)=0 or $icd='false' or hl7:interpretationCode/@nullFlavor or hl7:interpretationCode/@code=('POS','NEG','IND')  
  Message Observations with code <value-of select="$oc"/> shall have a interpretationCode element that shall be valued with POS','NEG' or 'IND'.  
hl7:entryRelationship
 0 … * R
(de-CH) Allfällige Bemerkungen

Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC) 		(Vitdotsion)
treeblank where [hl7:act [hl7:templateId [@root = '2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
@typeCode
 1 … 1 F SUBJ