2.16.840.1.113883.2.6.60.6.10.5

Aus Hl7wiki
Wechseln zu: Navigation, Suche
Hinweis zu dieser Seite

Template ClinicalInformationSection

Beschreibung

The Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen sent for investigation (including collection procedure, target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).

Aktuelle Version

Id2.16.840.1.113883.2.6.60.6.10.5Gültigkeit gültig ab 2014‑05‑13 14:38:08
StatusKyellow.png EntwurfVersions-Label
NameClinicalInformationSectionAnzeigenameClinical Information Section
BeschreibungThe Clinical Information section contains the information provided by the ordering physician: Clinical history, preoperative diagnosis, postoperative diagnosis, reason for anatomic pathology procedure, clinical laboratory data, specimen sent for investigation (including collection procedure, target site, performer, specimen type, specimen(s) clinical description, and tumor site in case of a cancer).
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.5
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 1 Konzept
IdNameDatensatz
psr-data​element-40klinische InformationPSR
Benutzt von / Benutzt
Benutzt von 1 Template, Benutzt 4 Templates
Benutzt von Template-Id als NameVersion
2.16.840.1.113883.2.6.60.6.10.1ContainmentPathology Structured Report2014‑05‑13 11:57:57
Benutzt Template-Id als NameVersion
1.2.276.0.76.10.90025ContainmentCDAAuthorBodyDYNAMIC
2.16.840.1.113883.2.6.60.6.10.34ContainmentProblemOrganizerDYNAMIC
1.2.276.0.76.10.3002InklusionReasonForReferralDYNAMIC
1.2.276.0.76.10.3022InklusionHistoryofpresentillnesssectionDYNAMIC
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
Beispiel
Beispiel
<section>
  <templateId root="2.16.840.1.113883.2.6.60.6.10.5"/>
  <code code="22636-5" codeSystem="2.16.840.1.113883.6.1" displayName="Pathology report relevant history"/>
  <title/>
  <text/>
  <languageCode code=""/>
  <author>
    <!-- template CDAAuthorBody (dynamic) -->
  </author>
  <component>
    <!-- include Reason for Referral Section (dynamic) 0..1 O-->
  </component>
  <component>
    <!-- include History of Present Illness Section (dynamic) 0..1 O-->
  </component>
</section>
ItemDTKardKonfBeschreibungLabel
hl7:section
0 … *(ClinicalInformationSection)
Treetree.png@classCode
0 … 1FDOCSECT
Treetree.png@moodCode
0 … 1FEVN
 Target.pngZiel der Konzept Id(s):
psr-data​element-40klinische InformationPSR
Treetree.pnghl7:templateId
II1 … 1R(ClinicalInformationSection)
Treeblank.pngTreetree.png@root
1 … 1F2.16.840.1.113883.2.6.60.6.10.5
Treetree.pnghl7:code
CE0 … 1(ClinicalInformationSection)
Treeblank.pngTreetree.png@code
1 … 1F22636-5
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreetree.png@displayName
1 … 1FPathology report relevant history
Treeblank.pngTreetree.png@codeSystemName
1 … 1FLOINC
Treetree.pnghl7:title
ST0 … 1(ClinicalInformationSection)
 Beispiel<title>CLINICAL INFORMATION</title>
Treetree.pnghl7:text
SD.TEXT0 … 1R(ClinicalInformationSection)
 Beispiel<text> Tissue submitted: left breast biopsy and apical axillary tissue </text>
Treetree.pnghl7:language​Code
CS0 … 1(ClinicalInformationSection)
 CONF
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
Treetree.pnghl7:author
0 … *Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC)(ClinicalInformationSection)
Treetree.pnghl7:entry
0 … *Beinhaltet 2.16.840.1.113883.2.6.60.6.10.34 Problem Organizer (DYNAMIC)(ClinicalInformationSection)
Treetree.pnghl7:component
0 … *(ClinicalInformationSection)
Eingefügt 0 … 1 von 1.2.276.0.76.10.3002 Grund der Überweisung Section (DYNAMIC)
Treeblank.pngTreetree.pnghl7:section
0 … 1(ClinicalInformationSection)
Treeblank.pngTreeblank.pngTreetree.pnghl7:templateId
II1 … 1(ClinicalInformationSection)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
1 … 1F1.2.276.0.76.10.3002
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE1 … 1M(ClinicalInformationSection)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
1 … 1F42349-1
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
 Beispiel<code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
Treeblank.pngTreeblank.pngTreetree.pnghl7:title
1 … 1M(ClinicalInformationSection)
 CONF
Elementinhalt muss "Grund der Überweisung" sein
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
SD.TEXT1 … 1MHier wird die eigentliche Fragestellung platziert.(ClinicalInformationSection)
Treetree.pnghl7:component
0 … *(ClinicalInformationSection)
Eingefügt 0 … 1 von 1.2.276.0.76.10.3022 Jetzige Anamnese (DYNAMIC)
Treeblank.pngTreetree.pnghl7:section
0 … 1(ClinicalInformationSection)
Treeblank.pngTreeblank.pngTreetree.pnghl7:templateId
II1 … 1(ClinicalInformationSection)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
1 … 1F1.2.276.0.76.10.3022
Treeblank.pngTreeblank.pngTreetree.pnghl7:code
CE1 … 1M(ClinicalInformationSection)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@code
1 … 1F10164-2
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
Treeblank.pngTreeblank.pngTreetree.pnghl7:title
ST1 … 1M(ClinicalInformationSection)
 CONF
Elementinhalt muss "Jetzige Anamnese" sein
Treeblank.pngTreeblank.pngTreetree.pnghl7:text
SD.TEXT1 … 1M(ClinicalInformationSection)

Zusammenstellung aller Versionen dieses Templates