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draft Template  Review Of Systems Observation

Id 2.16.756.5.30.1.1.10.4.109 Effective Date 2017‑09‑15 16:35:23
Status draft Draft Version Label 2018
Name cdachsmcp_entry_ReviewOfSystemsObservation Display Name Review Of Systems Observation
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.109
Label CDA‑CH‑SMCP
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 13 concepts
Id Name Data Set
cdachsmcp-dataelement-175 draft Field 14.12 (Etat cognitif) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-166 draft Field 14.3 (Elimination) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-170 draft Field 14.7 (Douleur) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-165 draft Field 14.2 (Alimentation, hydratation, état nutritionnel) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-174 draft Field 14.11 (Violence envers soi-même ou autrui) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-169 draft Field 14.6 (Addictions) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-172 draft Field 14.9 (Fugue, déambulation, errance) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-171 draft Field 14.8 (Humeur) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-168 draft Field 14.5 (Mobilité) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-173 draft Field 14.10 (Sommeil, fatigue) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-164 draft Field 14.1 (Respiration) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-176 draft Field 14.13 (Autres) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-167 draft Field 14.4 (Etat de la peau, plaies, cicatrices) draft DMST v3.1 - Etat de Vaud 7.8 updated
Used by / Uses
Used by 0 transactions and 2 templates, Uses 0 templates
Used by as Name Version
2.16.756.5.30.1.1.10.3.56 Containment draft Review of Systems Section - coded (2018) 2017‑09‑13 16:23:25
2.16.756.5.30.1.1.10.1.11 link draft Social-medical care plan V2 (2018) 2017‑08‑24 18:00:03
Relationship Specialization: template 2.16.756.5.30.1.1.10.4.71 Simple Observation (DYNAMIC)
ref
ch-pcc-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.13 (2016‑09‑26 08:43:40)
ref
?

Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.756.5.30.1.1.10.4.109"/>  <templateId root="2.16.756.5.30.1.1.10.4.71"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>  <id root="AC31A119-1F0A-431C-95BB-7A4827C63CDF"/>  <code code="11412-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Physical findings of Respiratory system Narrative"/>  <text>
    <reference value="#your_content_id"/>  </text>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NASK"/>  <value xsi:type="CD" nullFlavor="NAV"/></observation>
Item DT Card Conf Description Label
hl7:observation
 CDA-dotsSMCP
@classCode
 cs 1 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.109
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.71
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:id
 II 1 … 1 M CDA-dotsSMCP
hl7:code
 CD 1 … 1 M CDA-dotsSMCP
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.1.1.3.6.3.11.4 Review Of Systems Elements (DYNAMIC)
hl7:text
 ED 1 … 1 M CDA-dotsSMCP
 
target
cdachsmcp-dataelement-175 draft Field 14.12 (Etat cognitif) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-166 draft Field 14.3 (Elimination) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-170 draft Field 14.7 (Douleur) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-165 draft Field 14.2 (Alimentation, hydratation, état nutritionnel) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-174 draft Field 14.11 (Violence envers soi-même ou autrui) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-169 draft Field 14.6 (Addictions) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-172 draft Field 14.9 (Fugue, déambulation, errance) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-171 draft Field 14.8 (Humeur) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-168 draft Field 14.5 (Mobilité) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-173 draft Field 14.10 (Sommeil, fatigue) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-164 draft Field 14.1 (Respiration) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-176 draft Field 14.13 (Autres) draft DMST v3.1 - Etat de Vaud 7.8 updated
cdachsmcp-dataelement-167 draft Field 14.4 (Etat de la peau, plaies, cicatrices) draft DMST v3.1 - Etat de Vaud 7.8 updated
hl7:reference
 TEL 0 … 1 CDA-dotsSMCP
@value
 st 1 … 1 R
hl7:statusCode
 CS 1 … 1 M CDA-dotsSMCP
@code
 cs 1 … 1 F completed
Choice 1 … 1 Elements to choose from:
  • hl7:effectiveTime
  • hl7:effectiveTime
hl7:effectiveTime
 TS 0 … 1 R CDA-dotsSMCP
hl7:effectiveTime
 IVL_TS 0 … 1 R CDA-dotsSMCP
hl7:low
 IVXB_TS CDA-dotsSMCP
hl7:high
 IVXB_TS CDA-dotsSMCP
hl7:value
 ANY 1 … * R CDA-dotsSMCP