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draft Template  Social History Section - coded

Id 2.16.756.5.30.1.1.10.3.58 Effective Date 2017‑09‑13 16:52:50
Status draft Draft Version Label 2018
Name cdachsmcp_section_SocialHistoryCoded Display Name Social History Section - coded
Description The social history section shall contain a narrative description of the person’s beliefs, home life, community life, work life, hobbies, and risky habits. It shall include Social History Observations.
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.3.58
Label CDA‑CH‑SMCP
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 1 template
Used by as Name Version
2.16.756.5.30.1.1.10.1.11 Containment draft Social-medical care plan V2 (2018) 2017‑08‑24 18:00:03
Uses as Name Version
2.16.756.5.30.1.1.10.4.103 Containment draft Social History Observation (2018) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.3.24 Social History Section - plain text (DYNAMIC)
ref
ch-pcc-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.3.16.1 (2015‑10‑05 15:49:20)
ref
?

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.3.16 IHE Social History Section (2015‑10‑05 15:39:09)
ref
IHE-PCC-

Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.1.15 Social history section (2007‑04‑01)
ref
ccd1-
Example
Example
<section>
  <templateId root="2.16.756.5.30.1.1.10.3.58"/>  <templateId root="2.16.756.5.30.1.1.10.3.24"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.16.1"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.16"/>  <templateId root="2.16.840.1.113883.10.20.1.15"/>  <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Social history"/>  <title>Anamnèse sociale</title>  <text>Narrative text</text>  <entry>
    <!-- template 2.16.756.5.30.1.1.10.4.103 'Social History Observation' -->
  </entry></section>
Item DT Card Conf Description Label
hl7:section
 CDA-dotsSMCP
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.3.58
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.3.24
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.16.1
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.16
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.15
hl7:code
 CE 1 … 1 M Fixed, machine readable code of this section. CDA-dotsSMCP
@code
 CONF 1 … 1 F 29762-2
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@codeSystemName
 1 … 1 F LOINC
@displayName
 1 … 1 F Social history
hl7:title
 ST 1 … 1 M Fixed human readable title of this section.
  • [ge]: 'Sozialanamnese'
  • [fr]: 'Anamnèse sociale'
  • [en]: 'Social History'
 CDA-dotsSMCP
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='ge') or (text()='Sozialanamnese')  
  Message The German title must read 'Sozialanamnese'  
  Schematron assert role red error  
  test not($languageCode='fr') or (text()='Anamnèse sociale')  
  Message The French title must read 'Anamnèse sociale'  
  Schematron assert role red error  
  test not($languageCode='en') or (text()='Social History')  
  Message The English title must read 'Social History'  
hl7:text
 SD.TEXT 1 … 1 M Human readable text of this section. CDA-dotsSMCP
hl7:entry
 1 … * R Contains 2.16.756.5.30.1.1.10.4.103 Social History Observation (DYNAMIC) CDA-dotsSMCP
treeblank where [hl7:observation [hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.103'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.4.69'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.4.13.4'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.4.13'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.33']]]
  Schematron assert role red error  
  test count(hl7:entry/hl7:observation[hl7:code/@code=('1.20')])=1  
  Message The field 1.20 (Mandat pour inaptitude) is required in exactly one entry.  
  Schematron assert role red error  
  test count(hl7:entry/hl7:observation[hl7:code/@code=('1.21')])=1  
  Message The field 1.21 (Plan de crise conjoint) is required in exactly one entry.  
  Schematron assert role red error  
  test count(hl7:entry/hl7:observation[hl7:code/@code=('7.1')])=1  
  Message The field 7.1 (Date de l’évaluation) is required in exactly one entry.  
  Schematron assert role red error  
  test count(hl7:entry/hl7:observation[hl7:code/@code=('81334-5')])=1  
  Message The field 7.5 (Projet de la personne) is required in exactly one entry.