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Template VitalSignsCDAdocument

Actual version

IdEffective Date2014‑07‑08
StatusKyellow.png DraftVersion Label
NameVitalSignsCDAdocumentDisplay NameVital Signs Summary CDA document
Description
A minimal CDA Release 2 document, that contains only a few attributes and relationships for the ClinicalDocument class:
  • typeId: fixed
  • id: unique id of the document instance
  • code: type of document
  • effectiveTime: creation date of the document
  • confidentialityCode: confidentiality level indication for this document
  • recordTarget: the record target (e.g. patient)
  • author: author of this document
  • custodian: custodian for this document
  • component: contains (in this case) structured body
ContextPathname /
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Uses
Uses 9 templates
Used by as NameVersion
demo5-transaction-101TransactionKyellow.png Summary Vital Signs2014‑07‑08
Uses as NameVersion
2.16.840.1.113883.3.1937.99.60.5.10.900001IncludeKgreen.png CDA typeIdDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900002IncludeKgreen.png CDA idDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900003IncludeKgreen.png CDA titleDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900004IncludeKgreen.png CDA effectiveTimeDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900005IncludeKgreen.png CDA confidentialityCodeDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.2001IncludeKgreen.png CDA recordTargetDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.2002IncludeKgreen.png CDA authorDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.2003IncludeKgreen.png CDA custodianDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.3001ContainmentKyellow.png Vital Signs Section2014‑07‑08
Relationship
Specialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-
Example
Example
<ClinicalDocument>
  <!-- CDA Header -->
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>  <templateId root="2.16.840.1.113883.3.1937.99.60.5.10.1"/>  <id extension="38457384973598" root="2.16.840.1.113883.3.1937.99.3.2.56754657.1"/>  <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Assessment note"/>  <effectiveTime value="20140708123456"/>  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>  <recordTarget>
    <!-- .. -->
  </recordTarget>  <author>
    <!-- .. -->
  </author>  <custodian>
    <!-- .. -->
  </custodian>  <!-- CDA Body -->
  <component>
    <structuredBody>
      <component>
        <!-- .. -->
      </component>    </structuredBody>  </component></ClinicalDocument>
ItemDTCardConfDescriptionLabel
hl7:ClinicalDocument
(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900001 CDA typeId (DYNAMIC)
Treetree.pnghl7:typeId
II1 … 1MCDAtypeId
Treeblank.pngTreetree.png@extension
1 … 1FPOCD_HD000040
Treeblank.pngTreetree.png@root
1 … 1F2.16.840.1.113883.1.3
Treetree.pnghl7:templateId
II1 … 1MCDA document template id for this kind of document(Vit...ent)
Treeblank.pngTreetree.png@root
1 … 1F2.16.840.1.113883.3.1937.99.60.5.10.1
 Example<templateId root="2.16.840.1.113883.3.1937.99.60.5.10.1"/>
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900002 CDA id (DYNAMIC)
Treetree.pnghl7:id
II1 … 1M(Vit...ent)
Treetree.pnghl7:code
CE1 … 1M(Vit...ent)
Treeblank.pngTreetree.png@code
CONF1 … 1F51848-0
Treeblank.pngTreetree.png@codeSystem
1 … 1F2.16.840.1.113883.6.1 (LOINC)
Included0 … 1 from 2.16.840.1.113883.3.1937.99.60.5.10.900003 CDA title (DYNAMIC)
 Example<title>Assessment Note as of 8 July 2014</title>
Treetree.pnghl7:title
ST0 … 1(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900004 CDA effectiveTime (DYNAMIC)
Treetree.pnghl7:effectiveTime
TS.​DATE​TIME.​MIN1 … 1M(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900005 CDA confidentialityCode (DYNAMIC)
Treetree.pnghl7:confidentialityCode
CE1 … 1M(Vit...ent)
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 x_BasicConfidentialityKind (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.2001 CDA recordTarget (DYNAMIC)
Treetree.pnghl7:recordTarget
(Vit...ent)
 
Target.png
demo5-data​element-10Kyellow.png Person
Treeblank.pngTreetree.png@typeCode
0 … 1FRCT
Treeblank.pngTreetree.png@context​Control​Code
0 … 1FOP
Treeblank.pngTreetree.pnghl7:patientRole
1 … 1(Vit...ent)
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPAT
Included1 … 1R from 2.16.840.1.113883.3.1937.99.60.5.10.900207 Burgerservicenummer (DYNAMIC)
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II.NL.BSN1 … 1R(Vit...ent)
 
Target.png
demo5-data​element-110Kyellow.png National Patient Identifier
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@root
1 … 1F2.16.840.1.113883.2.4.6.3
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@extension
1 … 1RNational Patient Identifier (Burgerservicenummer)
Treeblank.pngTreeblank.pngTreetree.pnghl7:patient
1 … 1R(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
 Example<patient classCode="PSN" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>  <birthTime value="19620219"/></patient>
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … *R(Vit...ent)
 
Target.png
demo5-data​element-100Kyellow.png Name
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:administrative​Gender​Code
CE1 … 1R(Vit...ent)
 
Target.png
demo5-data​element-130Kyellow.png Gender
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:birthTime
TS1 … 1R(Vit...ent)
 
Target.png
demo5-data​element-120Kyellow.png Date of birth
Included from 2.16.840.1.113883.3.1937.99.60.5.10.2002 CDA author (DYNAMIC)
Treetree.pnghl7:author
1 … *M(Vit...ent)
Treeblank.pngTreetree.png@typeCode
0 … 1FAUT
Treeblank.pngTreetree.pnghl7:time
TS.​DATE.​MIN1 … 1M(Vit...ent)
Treeblank.pngTreetree.pnghl7:assignedAuthor
1 … 1M(Vit...ent)
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:id
II1 … 1R(Vit...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:assigned​Person
0 … 1(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900200 CDA Person Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FPSN
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
PN1 … 1M(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:family
ST1 … 1M(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:given
ST1 … 1M(Vit...ent)
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Organization
0 … 1(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900201 CDA Organization Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1M(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.2003 CDA custodian (DYNAMIC)
Treetree.pnghl7:custodian
1 … 1M(Vit...ent)
Treeblank.pngTreetree.png@typeCode
0 … 1FCST
Treeblank.pngTreetree.pnghl7:assignedCustodian
1 … 1M(Vit...ent)
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FASSIGNED
Treeblank.pngTreeblank.pngTreetree.pnghl7:represented​Custodian​Organization
0 … 1(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900201 CDA Organization Elements (DYNAMIC)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@classCode
cs0 … 1FORG
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@determiner​Code
cs0 … 1FINSTANCE
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:id
II0 … *(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:name
ON1 … 1M(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:telecom
TEL0 … *(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.pnghl7:addr
AD0 … 1(Vit...ent)
Treetree.pnghl7:component
(Vit...ent)
Treeblank.pngTreetree.png@typeCode
0 … 1FCOMP
Treeblank.pngTreetree.png@context​Conduction​Ind
0 … 1Ftrue
Treeblank.pngTreetree.pnghl7:structuredBody
(Vit...ent)
Treeblank.pngTreeblank.pngTreetree.png@classCode
0 … 1FDOCBODY
Treeblank.pngTreeblank.pngTreetree.png@moodCode
0 … 1FEVN
Treeblank.pngTreeblank.pngTreetree.pnghl7:component
1 … 1MContains 2.16.840.1.113883.3.1937.99.60.5.10.3001 Vital Signs Section (2014‑07‑08)(Vit...ent)
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@typeCode
0 … 1FCOMP
Treeblank.pngTreeblank.pngTreeblank.pngTreetree.png@context​Conduction​Ind
0 … 1Ftrue


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