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Version vom 24. März 2020, 15:06 Uhr

Id2.16.840.1.113883.3.1937.99.60.5.10.1Effective Date2014‑07‑08
Status 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)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 9 templates
Uses as NameVersion
2.16.840.1.113883.3.1937.99.60.5.10.900001Include CDA typeIdDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900002Include CDA idDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900003Include CDA titleDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900004Include CDA effectiveTimeDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.900005Include CDA confidentialityCodeDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.2001Include CDA recordTargetDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.2002Include CDA authorDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.2003Include CDA custodianDYNAMIC
2.16.840.1.113883.3.1937.99.60.5.10.3001Containment Vital Signs Section2014‑07‑08
RelationshipSpecialization: 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)
hl7:typeId
II1 … 1MCDAtypeId
@extension
1 … 1FPOCD_HD000040
@root
1 … 1F2.16.840.1.113883.1.3
hl7:templateId
II1 … 1MCDA document template id for this kind of document(Vit...ent)
@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)
hl7:id
II1 … 1M(Vit...ent)
hl7:code
CE1 … 1M(Vit...ent)
@code
CONF1 … 1F51848-0
@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>
hl7:title
ST0 … 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.​MIN1 … 1M(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900005 CDA confidentialityCode (DYNAMIC)
hl7: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)
hl7:recordTarget
(Vit...ent)
 
demo5-data​element-10 Person  Demo 5 dataset
@typeCode
0 … 1FRCT
@context​Control​Code
0 … 1FOP
hl7:patientRole
1 … 1(Vit...ent)
@classCode
0 … 1FPAT
Included1 … 1R from 2.16.840.1.113883.3.1937.99.60.5.10.900207 Burgerservicenummer (DYNAMIC)
hl7:id
II.NL.BSN1 … 1R(Vit...ent)
 
demo5-data​element-110 National Patient Identifier  Demo 5 dataset
@root
1 … 1F2.16.840.1.113883.2.4.6.3
@extension
1 … 1RNational Patient Identifier (Burgerservicenummer)
hl7:patient
1 … 1R(Vit...ent)
@classCode
0 … 1FPSN
@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>
hl7:name
PN1 … *R(Vit...ent)
 
demo5-data​element-100 Name  Demo 5 dataset
hl7:administrative​Gender​Code
CE1 … 1R(Vit...ent)
 
demo5-data​element-130 Gender  Demo 5 dataset
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
hl7:birthTime
TS1 … 1R(Vit...ent)
 
demo5-data​element-120 Date of birth  Demo 5 dataset
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 … 1FAUT
hl7:time
TS.​DATE.​MIN1 … 1M(Vit...ent)
hl7:assignedAuthor
1 … 1M(Vit...ent)
@classCode
0 … 1FASSIGNED
hl7:id
II1 … 1R(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 … 1FPSN
@determiner​Code
0 … 1FINSTANCE
hl7:name
PN1 … 1M(Vit...ent)
hl7:family
ST1 … 1M(Vit...ent)
hl7:given
ST1 … 1M(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
0 … 1FORG
@determiner​Code
0 … 1FINSTANCE
hl7:id
II0 … *(Vit...ent)
hl7:name
ON1 … 1M(Vit...ent)
hl7:telecom
TEL0 … *(Vit...ent)
hl7:addr
AD0 … 1(Vit...ent)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.2003 CDA custodian (DYNAMIC)
hl7:custodian
1 … 1M(Vit...ent)
@typeCode
0 … 1FCST
hl7:assignedCustodian
1 … 1M(Vit...ent)
@classCode
0 … 1FASSIGNED
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
0 … 1FORG
@determiner​Code
0 … 1FINSTANCE
hl7:id
II0 … *(Vit...ent)
hl7:name
ON1 … 1M(Vit...ent)
hl7:telecom
TEL0 … *(Vit...ent)
hl7:addr
AD0 … 1(Vit...ent)
hl7:component
(Vit...ent)
@typeCode
0 … 1FCOMP
@context​Conduction​Ind
0 … 1Ftrue
hl7:structuredBody
(Vit...ent)
@classCode
0 … 1FDOCBODY
@moodCode
0 … 1FEVN
hl7:component
1 … 1MContains 2.16.840.1.113883.3.1937.99.60.5.10.3001 Vital Signs Section (2014‑07‑08)(Vit...ent)
where [hl7:section [hl7:code [(@code = '8716-3' and @codeSystem = '2.16.840.1.113883.6.1')]]]
@typeCode
0 … 1FCOMP
@context​Conduction​Ind
0 … 1Ftrue