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
| Id | 2.16.840.1.113883.2.6.60.6.10.5 | Gültigkeit | gültig ab 2014‑05‑13 14:38:08 |
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| Status |  Entwurf | Versions-Label | |
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| Name | ClinicalInformationSection | Anzeigename | Clinical Information Section |
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| 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). |
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| Kontext | Elternknoten des Template-Element mit Id 2.16.840.1.113883.2.6.60.6.10.5 |
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| Klassifikation | CDA Section level template |
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| Offen/Geschlossen | Offen (auch andere als die definierten Elemente sind erlaubt) |
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| Assoziiert mit | | Assoziiert mit 1 Konzept | | Id | Name | Datensatz |
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| psr-dataelement-40 | klinische Information | PSR |
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| Benutzt von / Benutzt | | Benutzt von 1 Template, Benutzt 4 Templates | | Benutzt von Template-Id | als | Name | Version |
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| 2.16.840.1.113883.2.6.60.6.10.1 | Containment | Pathology Structured Report | 2014‑05‑13 11:57:57 | | Benutzt Template-Id | als | Name | Version |
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| 1.2.276.0.76.10.90025 | Containment | CDAAuthorBody | DYNAMIC | | 2.16.840.1.113883.2.6.60.6.10.34 | Containment | ProblemOrganizer | DYNAMIC | | 1.2.276.0.76.10.3002 | Inklusion | ReasonForReferral | DYNAMIC | | 1.2.276.0.76.10.3022 | Inklusion | Historyofpresentillnesssection | DYNAMIC |
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| Beziehung | Spezialisierung: Template 2.16.840.1.113883.10.12.201 (2005‑09‑07) |
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| 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> |
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| Item | DT | Kard | Konf | Beschreibung | Label |
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| | 0 … * | | | (ClinicalInformationSection) |  | @classCode
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| | 0 … 1 | F | DOCSECT | | @moodCode
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| | 0 … 1 | F | EVN | | |  | Ziel der Konzept Id(s): | psr-dataelement-40 | klinische Information | PSR |
| | hl7:templateId
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| II | 1 … 1 | R | | (ClinicalInformationSection) |  | | @root
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| | 1 … 1 | F | 2.16.840.1.113883.2.6.60.6.10.5 | | hl7:code
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| CE | 0 … 1 | | | (ClinicalInformationSection) | | | @code
|
| | 1 … 1 | F | 22636-5 | | | @codeSystem
|
| | 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) | | | @displayName
|
| | 1 … 1 | F | Pathology report relevant history | | | @codeSystemName
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| | 1 … 1 | F | LOINC | | hl7:title
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| ST | 0 … 1 | | | (ClinicalInformationSection) | | | Beispiel | <title>CLINICAL INFORMATION</title> | | hl7:text
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| SD.TEXT | 0 … 1 | R | | (ClinicalInformationSection) | | | Beispiel | <text> Tissue submitted: left breast biopsy and apical axillary tissue </text> | | hl7:languageCode
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| CS | 0 … 1 | | | (ClinicalInformationSection) | | | CONF | | Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC) |
| | hl7:author
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| | 0 … * | | Beinhaltet 1.2.276.0.76.10.90025 CDA Author (Body) (DYNAMIC) | (ClinicalInformationSection) | | hl7:entry
|
| | 0 … * | | Beinhaltet 2.16.840.1.113883.2.6.60.6.10.34 Problem Organizer (DYNAMIC) | (ClinicalInformationSection) | | hl7:component
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| | 0 … * | | | (ClinicalInformationSection) | | Eingefügt 0 … 1 | von 1.2.276.0.76.10.3002 Grund der Überweisung Section (DYNAMIC) | | | hl7:section
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| | 0 … 1 | | | (ClinicalInformationSection) | | II | 1 … 1 | | | (ClinicalInformationSection) | | | 1 … 1 | F | 1.2.276.0.76.10.3002 | | CE | 1 … 1 | M | | (ClinicalInformationSection) | | | 1 … 1 | F | 42349-1 | | | 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) | | | Beispiel | <code code="42349-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
| | | 1 … 1 | M | | (ClinicalInformationSection) | | | CONF | | Elementinhalt muss "Grund der Überweisung" sein |
| | SD.TEXT | 1 … 1 | M | Hier wird die eigentliche Fragestellung platziert. | (ClinicalInformationSection) | | hl7:component
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| | 0 … * | | | (ClinicalInformationSection) | | Eingefügt 0 … 1 | von 1.2.276.0.76.10.3022 Jetzige Anamnese (DYNAMIC) | | | hl7:section
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| | 0 … 1 | | | (ClinicalInformationSection) | | II | 1 … 1 | | | (ClinicalInformationSection) | | | 1 … 1 | F | 1.2.276.0.76.10.3022 | | CE | 1 … 1 | M | | (ClinicalInformationSection) | | | 1 … 1 | F | 10164-2 | | | 1 … 1 | F | 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) | | ST | 1 … 1 | M | | (ClinicalInformationSection) | | | CONF | | Elementinhalt muss "Jetzige Anamnese" sein |
| | SD.TEXT | 1 … 1 | M | | (ClinicalInformationSection) |
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Zusammenstellung aller Versionen dieses Templates
Entwurf
