2.16.840.1.113883.3.1937.99.60.5.10.1

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Template VitalSignsCDAdocument

A minimal CDA Release 2 document, that contains only a few attributes and relationships for the ClinicalDocument class: typeId: fixedid: unique id of the document instancecode: type of documenteffectiveTime: creation date of the documentconfidentialityCode: confidentiality level indication for this documentrecordTarget: the record target (e.g. patient)author: author of this documentcustodian: custodian for this documentcomponent: contains (in this case) structured body

Actual version

Id		Effective Date	2014‑07‑08
Status	Draft	Version Label
Name	VitalSignsCDAdocument	Display Name	Vital 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
Context	Pathname /
Classification	CDA Document Level Template
Open/Closed	Open (other than defined elements are allowed)
Uses	Uses 9 templates Used by as Name Version demo5-transaction-101 Transaction Summary Vital Signs 2014‑07‑08 Uses as Name Version 2.16.840.1.113883.3.1937.99.60.5.10.900001 Include CDA typeId DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.900002 Include CDA id DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.900003 Include CDA title DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.900004 Include CDA effectiveTime DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.900005 Include CDA confidentialityCode DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.2001 Include CDA recordTarget DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.2002 Include CDA author DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.2003 Include CDA custodian DYNAMIC 2.16.840.1.113883.3.1937.99.60.5.10.3001 Containment Vital Signs Section 2014‑07‑08
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>
Item DT Card Conf Description Label hl7:ClinicalDocument (Vit...ent) Included from 2.16.840.1.113883.3.1937.99.60.5.10.900001 CDA typeId (DYNAMIC) hl7:typeId II 1 … 1 M CDAtypeId @extension 1 … 1 F POCD_HD000040 @root 1 … 1 F 2.16.840.1.113883.1.3 hl7:templateId II 1 … 1 M CDA document template id for this kind of document (Vit...ent) @root 1 … 1 F 2.16.840.1.113883.3.1937.99.60.5.10.1   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) hl7:id II 1 … 1 M (Vit...ent) hl7:code CE 1 … 1 M (Vit...ent) @code CONF 1 … 1 F 51848-0 @codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC) Included 0 … 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> hl7:title ST 0 … 1 (Vit...ent) Included from 2.16.840.1.113883.3.1937.99.60.5.10.900004 CDA effectiveTime (DYNAMIC) hl7:effectiveTime TS.​DATE​TIME.​MIN 1 … 1 M (Vit...ent) Included from 2.16.840.1.113883.3.1937.99.60.5.10.900005 CDA confidentialityCode (DYNAMIC) hl7:confidentialityCode CE 1 … 1 M (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) hl7:recordTarget (Vit...ent)   demo5-data​element-10  Person @typeCode 0 … 1 F RCT @context​Control​Code 0 … 1 F OP hl7:patientRole 1 … 1 (Vit...ent) @classCode 0 … 1 F PAT Included 1 … 1 R from 2.16.840.1.113883.3.1937.99.60.5.10.900207 Burgerservicenummer (DYNAMIC) hl7:id II.NL.BSN 1 … 1 R (Vit...ent)   demo5-data​element-110  National Patient Identifier @root 1 … 1 F 2.16.840.1.113883.2.4.6.3 @extension 1 … 1 R National Patient Identifier (Burgerservicenummer) hl7:patient 1 … 1 R (Vit...ent) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE   Example <patient classCode="PSN" determinerCode="INSTANCE">   <name>     <!-- ... -->   </name>  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>  <birthTime value="19620219"/></patient> hl7:name PN 1 … * R (Vit...ent)   demo5-data​element-100  Name hl7:administrative​Gender​Code CE 1 … 1 R (Vit...ent)   demo5-data​element-130  Gender   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC) hl7:birthTime TS 1 … 1 R (Vit...ent)   demo5-data​element-120  Date of birth Included from 2.16.840.1.113883.3.1937.99.60.5.10.2002 CDA author (DYNAMIC) hl7:author 1 … * M (Vit...ent) @typeCode 0 … 1 F AUT hl7:time TS.​DATE.​MIN 1 … 1 M (Vit...ent) hl7:assignedAuthor 1 … 1 M (Vit...ent) @classCode 0 … 1 F ASSIGNED hl7:id II 1 … 1 R (Vit...ent) hl7:assigned​Person 0 … 1 (Vit...ent) Included from 2.16.840.1.113883.3.1937.99.60.5.10.900200 CDA Person Elements (DYNAMIC) @classCode 0 … 1 F PSN @determiner​Code 0 … 1 F INSTANCE hl7:name PN 1 … 1 M (Vit...ent) hl7:family ST 1 … 1 M (Vit...ent) hl7:given ST 1 … 1 M (Vit...ent) hl7:represented​Organization 0 … 1 (Vit...ent) Included from 2.16.840.1.113883.3.1937.99.60.5.10.900201 CDA Organization Elements (DYNAMIC) @classCode cs 0 … 1 F ORG @determiner​Code cs 0 … 1 F INSTANCE hl7:id II 0 … * (Vit...ent) hl7:name ON 1 … 1 M (Vit...ent) hl7:telecom TEL 0 … * (Vit...ent) hl7:addr AD 0 … 1 (Vit...ent) Included from 2.16.840.1.113883.3.1937.99.60.5.10.2003 CDA custodian (DYNAMIC) hl7:custodian 1 … 1 M (Vit...ent) @typeCode 0 … 1 F CST hl7:assignedCustodian 1 … 1 M (Vit...ent) @classCode 0 … 1 F ASSIGNED hl7: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) @classCode cs 0 … 1 F ORG @determiner​Code cs 0 … 1 F INSTANCE hl7:id II 0 … * (Vit...ent) hl7:name ON 1 … 1 M (Vit...ent) hl7:telecom TEL 0 … * (Vit...ent) hl7:addr AD 0 … 1 (Vit...ent) hl7:component (Vit...ent) @typeCode 0 … 1 F COMP @context​Conduction​Ind 0 … 1 F true hl7:structuredBody (Vit...ent) @classCode 0 … 1 F DOCBODY @moodCode 0 … 1 F EVN hl7:component 1 … 1 M Contains 2.16.840.1.113883.3.1937.99.60.5.10.3001 Vital Signs Section (2014‑07‑08) (Vit...ent) @typeCode 0 … 1 F COMP @context​Conduction​Ind 0 … 1 F true

List of all versions of this template

• 2014-07-08 (Under develeopment)