Item | DT | Card | Conf | Description | Label |
---|
| | 0 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @classCode
|
| cs | 0 … 1 | F | DOCSECT |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @moodCode
|
| cs | 0 … 1 | F | EVN |
| Constraint | This section SHALL contain a code element populated with these attributes: @code="22636-5" @codeSystem="'2.16.840.1.113883.6.1" @displayName=" Pathology report relevant history” This section SHALL contain a narrative block, represented by a text element, which renders the information to the human reader.
The section SHOULD contain as many Problem Organizer entry elements as there are problems (or groups thereof) to be described. These entries provide the machine-readable data corresponding to the narrative block. This section MAY contain a number of elements component/section introducing sub-sections, each of these sub-sections providing a particular type of clinical information. This section SHOULD contain author elements in case the authors of this section differ from those declared at a higher level in the document. |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:templateId
|
| II | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @root
|
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.2.1 |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:code
|
| CE | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @code
|
| CONF | 1 … 1 | F | 22636-5 |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @codeSystem
|
| 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @displayName
|
| 1 … 1 | F | Pathology report relevant history |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @codeSystemName
|
| 1 … 1 | F | LOINC |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:title
|
| ST | 1 … 1 | R | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| CONF | element content shall be "CLINICAL INFORMATION SECTION" |
|
| Example | <title>CLINICAL INFORMATION</title> |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:text
|
| SD.TEXT | 1 … 1 | M | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| Example | <text> Tissue submitted: left breast biopsy and apical axillary tissue </text> |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:languageCode
|
| CS | 0 … 1 | | | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
| CONF | The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) |
|
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:entry
|
| ANY | 0 … * | R | Problem organizer Contains 1.3.6.1.4.1.19376.1.8.1.3.6 Problem Organizer (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @typeCode
|
| cs | 0 … 1 | F | COMP |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @contextConductionInd
|
| bl | 0 … 1 | F | true |
Included | 0 … * | C | from 1.3.6.1.4.1.19376.1.8.1.4.2 CDA author IHE (DYNAMIC) Source: PaLM Suppl. APSR 2.0-3: 6.3.6.2
|
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:author
|
| | 0 … * | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | @typeCode
|
| cs | 1 … 1 | F | AUT |
| Example | author is a person <author typeCode="AUT" contextControlCode="OP"> <time value="201306101654"/> <assignedAuthor classCode="ASSIGNED"> <!-- ... --> </assignedAuthor></author> |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:templateId
|
| | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.8.1.4.2 |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:time
|
| TS | 1 … 1 | M | The authoring time is the date & time that this author contributed to the document. It SHALL be provided. | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:assignedAuthor
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | ASSIGNED |
| II | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 1 … 1 | M | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
Choice | 1 … 1 | | The author is either an assigned person or an authoring device.
Elements to choose from:- hl7:assignedPerson
- hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
Included | 0 … * | | from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC) The name(s) SHALL be given. |
| | 0 … 1 | F | PSN |
| | 0 … 1 | F | INSTANCE |
| PN | 0 … * | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:assignedAuthoringDevice
|
| | 0 … 1 | C | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| cs | 0 … 1 | F | DEV |
| cs | 0 … 1 | F | INSTANCE |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:manufacturerModelName
|
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| SC | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| CE | 0 … 1 | R | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treeblank.png](/images/thumb/Treeblank.png/16px-Treeblank.png) | ![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:representedOrganization
|
| | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| Example | represented organization for author as a device <representedOrganization classCode="ORG" determinerCode="INSTANCE"> <name> <!-- ... --> </name></representedOrganization> |
Included | 0 … 1 | | from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC) The identifier(s) SHOULD, the name SHALL, the telecom(s) and the address(es) MAY be given. |
| | 0 … 1 | F | ORG |
| | 0 … 1 | F | INSTANCE |
| II | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| ON | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| TEL | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
| AD | 0 … 1 | | | PaLM Suppl.APSR 2.0‑3:6.3.6.2 Author |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:component
|
| | 0 … 1 | | Subsection
Source: PCC TF-2: 6.3.3.1.1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 IHE Reason for Referral Section (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:component
|
| | 0 … 1 | | Subsection
Source: PCC TF-2: 6.3.3.2.1 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |
![Treetree.png](/images/thumb/Treetree.png/16px-Treetree.png) | hl7:component
|
| | 0 … 1 | | Subsection
Source: PCC TF-2: 6.3.3.2.3 Contains 1.3.6.1.4.1.19376.1.5.3.1.3.6 IHE Active Problems Section (DYNAMIC) | PaLM Suppl. 2.0‑3: 6.3.4.1 Clinical information section |