Transcript
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Ghid implementare CDAVersion: 1.11

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Revision SheetChange Record

Date Author Version Comment09.11.2007 Adriana Sava 1 prima versiune06.03.2008 Radu Berca 1.1 completari14.03.2008 Doru Ungureanu 1.2 modificari16.04.2008 Andy Neagu 1.3 Adaugare anexa Pharmacy07.05.2008 Silvia Dusceac 1.4 Adaugare sectiuni&anexe pentru biletele de trimitere; Review09.05.2008 Silvia Dusceac 1.5 Completare sectiune Medicatie24.05.2008 Mihai Radu 1.6. Completare sectiunea Bilet de trimitere primit – PNS09.07.2008 Patrascu Andrei 1.7 Adaugare sectiuni:

Alergie, Antecedente familiale,Imunizari, Riscuri, Semne vitale copil, Estimare data nastere, Analiza retrospectiva organism, Consultatie prenatala, Acuze pacient, Concediu medicalModificare sectiune:Istoric afectiuni (adaugare tip antecedent)

25.03.2009 Vlad Racovita 1.8 Adaugat Recoltare Probe25.05.2009 Radu Berca 1.9 Diverse corectii si completari23.06.2009 Doru Ungureanu 1.10 Modificat numele sectiunii Prescriere medicatie in Medicatie. Adaugat descriere pt

moodCode.10.11.2010 Arthur Molnar 1.11 Sters sectiunea Programe Nationale de Sanatate, incorporat informatia in Billing15.06.2011 Arthur Molnar 1.12 Actualizat sectiunea Bilet de Trimitere Primit

ReviewersTeam Version DateMihai Cotu 1 17.11.2007Radu Berca 1.1 06.03.2008Silvia Dusceac 1.3 07.05.2008Doru Ungureanu 1.7 10.07.2008Silvia Dusceac 1.7 17.07.2008

Distribution

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Name PositionCristian Taslitchi Director Dep. SoftwareMihai Cotu Analist programator

Cuprins:Ghid implementare CDA.............................................................................................................................................................................................. 1Version: 1.9.................................................................................................................................................................................................................. 1Introducere................................................................................................................................................................................................................... 3CDA - Reguli................................................................................................................................................................................................................ 3

Sectiunile documentului CDA................................................................................................................................................................................... 3Cardinalitatea........................................................................................................................................................................................................... 3Obligatoriu/ Optional/ Cerut...................................................................................................................................................................................... 3Tipurile de date......................................................................................................................................................................................................... 3Vocabulare............................................................................................................................................................................................................... 3Entitati...................................................................................................................................................................................................................... 3

CDA – Sectiuni din header........................................................................................................................................................................................... 3Clinical Document.................................................................................................................................................................................................... 3

Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Record Target.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Author....................................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3

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Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Custodian................................................................................................................................................................................................................. 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Informatiile destinatarului.......................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Participant................................................................................................................................................................................................................ 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

inFulfillmentOf.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

relatedDocument...................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Component Of.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

CDA – Sectiuni din body.............................................................................................................................................................................................. 3Billing........................................................................................................................................................................................................................ 3

Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Istoric afectiuni......................................................................................................................................................................................................... 3Cardinalitate.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

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Semne vitale............................................................................................................................................................................................................. 3Cardinalitate.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Examen Clinic.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Medicatie.................................................................................................................................................................................................................. 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Note:..................................................................................................................................................................................................................... 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Diagnostice............................................................................................................................................................................................................... 3Cardinalitate.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Proceduri.................................................................................................................................................................................................................. 3Cardinalitate.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Cerere proceduri imagistica...................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Cerere laborator....................................................................................................................................................................................................... 3Cardinalitate.......................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3

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Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Rezultate laborator................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Bilet de trimitere primit.............................................................................................................................................................................................. 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Bilet de trimitere emis............................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Alergii....................................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Antecedente familiale............................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Imunizari................................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Riscuri...................................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

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Narativ.................................................................................................................................................................................................................. 3Semne vitale copil.................................................................................................................................................................................................... 3

Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Estimare data nastere.............................................................................................................................................................................................. 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Istoric Menstruatie(Review of Systems)................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Consultatie prenatala............................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Tipuri de observatie.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Acuze....................................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Concediu medical..................................................................................................................................................................................................... 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

Lapte praf................................................................................................................................................................................................................. 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3Narativ.................................................................................................................................................................................................................. 3

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Recoltare probe........................................................................................................................................................................................................ 3Descriere.............................................................................................................................................................................................................. 3Elemente si atribute.............................................................................................................................................................................................. 3Exemplu................................................................................................................................................................................................................ 3

Anexe........................................................................................................................................................................................................................... 3Pharmacy................................................................................................................................................................................................................. 3

Precizari implemenentare sectiuni prescriere si eliberare medicamente..............................................................................................................3Precizari fluxuri procesare sectiuni prescriere si eliberare medicamente:.............................................................................................................3

Bilete de trimitere..................................................................................................................................................................................................... 3Precizari implemenentare bilete de trimitere primite............................................................................................................................................. 3Precizari implementare bilete de trimitere emise.................................................................................................................................................. 3

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IntroducereScopul acestui document este de a descrie sectiune cu sectiune implementarea in standardul HL7 CDA a diferitelor sectiuni medicale ce documenteaza un act medical. Scopul acestui documentul este standardizarea documentelor medicale in vederea interschimbarii lor intre diferite sisteme informatice pentru a gestiona in comun informatiile medicale ale pacientilor.

CDA - Reguli

Sectiunile documentului CDA

Un document CDA este format din doua parti, header si body. Header-ul CDA-ului este continut in toate documentele CDA indiferent de tipul documentului, identifica si clasifica documentul si furnizeaza informatia la autentificare: vizita, pacientul si furnizorii implicati. Body-ul contine raportul clinic si poate fi o combinatie intre textul structurat si/sau elemente xml structurate . Fiecare sectiune din body-ul documentul CDA poate fi doar text sau poate avea elemente discrete de date impreuna cu textul.

Cardinalitatea

Rolul de cardinalitate exista pentru fiecare sectiune si fiecare element individual de date dintr-o sectiune. Cardinalitatea este reprezentata de 0, 1, 2 sau * indicand cardinalitatea maxima. De exemplu 0..* indica o cardinalitate minima 0 si o cardinalitate maxima de oricate elemente.Urmatorul tabel exemplifica diferitele tipuri de cardinalitate care pot fi definite pentru sectiuni si elemente de date.

Cardinalitate Descriere0..1 Sectiunea si elementele de date pot avea 0 sau o instanta1..1 Sectiunea si elementele de date pot avea exact o singura instanta0..* Sectiunea si elementele de date pot avea 0 sau mai multe instante1..* Sectiunea si elementele de date pot avea 1 sau mai multe instante2..2 Sectiunea si elementele de date pot avea exact doua instante

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Obligatoriu/ Optional/ Cerut

Fiecare sectiune si fiecare element de date dintr-o sectiune este definit ca obligatoriu, optional sau cerut.

Daca o sectiune sau un element de date este obligatoriu (indicata de “M”) trebuie sa fie prezenta in document, altfel documentul este invalid si este neconform. Cardinalitatea minima pentru toate elementele obligatorii este 1.

Daca o sectiune sau un element de date este cerut (indicat de “R”), aplicatia trimitatoare trebuie sa suporte acest camp. Cu alte cuvinte daca datele nu sunt disponibile, atunci campul trebuie sa fie inclus in document. Daca cardinalitatea minima este 0 si datele nu sunt disponibile, campul poate fi omis din document si poate fi inca conform. Daca cardinalitatea minima este 1 si datele nu sunt disponibile, NullFlavor este cerut pentru a fi trimis (de exemplu: fara informatii, necunoscut, mascat, intrebat si neintrebat, dar necunoscut).

Daca o sectiune sau un element de date este optional (indicat de “O”), sectiunea sau elementul de date poate sau nu poate fi trimis si suportat. Aplicatia care primeste s-ar putea sa nu poata admite prezenta acestul element in document.

Daca o sectiune sau un element de date nu este suportat sau codificat (indicat de “X”) sectiunea sau elementul de date nu trebuie sa fie inclus in document. Includerea acestui element in document ar fi neconforma.

Tipurile de date

Fiecare element de date are un tip de data asociat. Urmatorul tabel indica descrierile HL7 ale tipurilor de date folosite in documentele CDA.

Tipul de date Nume DescriereAD Adresa postala Adresa postala de acasa sau de la servici. O secventa ale

partilor unei adrese, cum ar fi strada si numar, orasul, codul postal, tara.

ANY Orice Defineste proprietatile de baza ale fiecarui tip de date. Acesta este un tip abstract si nu poate fi instantiat. Fiecare tip concret este o specializare a lui ANY.

CD Descrierea conceptului

Un CD reprezinta orice tip de concept avand un cod definit intr-un sistem de codificare (vocabular sau nomenclator). Un CD poate contine textul original sau fraza care serveste ca

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baza de codificare si una sau mai multe translatari in diferite sisteme de codificare. Un CD poate deasemenea contine calificari pentru descriere. De exemplu, conceptul “picior stang” este creat din codul “picior” si calificatorul “stang”. In cazuri exceptionale descrierea conceptului poate sa nu contina codul ci doar textul original descris in concept.

CE Codificare cu echivalenti

Date codificate care contin valori codificate (CV) si optional valori codate din alte coding system-uri care identifica acelasi concept. Folosite cand coduri alternative ar putea exista.

CS Valori codate simple

Date codate in formele lor simple, unde doar codul nu este predeterminat. Code system-ul si versiunea code system-ului este fixata in context unde apare valoare CS-ului.

ED Date encapsulate

Date care sunt intentionate pentru interpretarea umana sau pentru o procesare ulterioara in afara scopului HL7. Aceasta include text formatat sau neformatat, date multimedia sau informatii structurale definite de diferite standarde

EN Numele entitatii Numele unei persoane, organizatie, loc sau lucru. O secventa de parti din nume cum ar fi numele sau prenumele, sufixul, prefixul, etc

II Identificatorul instantei

Un identificator unic pentru un lucru sau un obiect. Exemple sunt obiectele identificate pentru obiectele HL7 RIM, numele inregistrarilor medicale, Identificatorul cererii, Identificatorul unui element din catalogul cu servicii, numarul de identificare al vechicolului (VIN), etc. Identificatorii instantelor sunt definiti pe baza identificatorilor de obiecte ISO.

IVL Interval Un set de valori consecutive ale unui tip de date de baza ordonat. Fiecare tip ordonat poate fi baza unui interval. Nu conteaza daca tipul de baza este discret sau continuu. Daca tipul de baza este partial ordonat, toate elementele din interval trebuie sa fie elemente unui subset total ordonat

ON Numele organizatiei

Un EN utilizat cand entitatea este o organizatie. O secventa de parti de nume.

PN Nume personal Un EN utilizat cand entitatea este o persoana. O seceventa de parti de nume, cum ar fi nume sau prenume, prefix, sufix, etc.

PQ Cantitatea fizica O cantitate dimensionata care exprima rezultatul unei masuratori

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RTO Proportia (Raportul)

O cantitate construita ca un coeficient a unei cantitati divizata de un numitor. Factorul comun la numarator si numitor nu se simplifica automat. Tipul de date suporta titru (exemplu: “1:128”) si alte cantitati produse de laboratoare care reprezinta fractii

SC Caracterul string cu coduri

Un sir de caractere care optional ar putea avea coduri atasate. Textul trebuie sa fie tot timpul prezent daca un cod este prezent. Codul este de cele mai multe ori un cod local.

ST Caracter string Un sir de caractere facut in primul rand pentru procesarea de catre calculator (sortare, indexare, interogare, etc). Folosit pentru nume, simboluri si expresii formale

TEL Adrese de telecomunicare

Un numar de telefon (voce sau fax), adresa de e-mail, sau alte locatii care folosesc echimpamente de telecomunicatii. Adresa este specificata ca Universal Resource Locator (URL) calificat de specificatiile timpului si care foloseste coduri care ajuta la deciderea carei adrese sa fie folosite la un moment dat si scop. A se nota ca spatiile din acest tip de date nu sunt valide, desi aceasta nu este momentan constransa de HL7

TS Timestamp O cantitate care specifica un punct aflat pe o axa a timpului. Un punct in timp este adesa reprezentat de o expresie calendaristica. Nota: un IVL TS (Interval Timestamp) trebuie sa fie total format, pentru ca un TS sa fie delimitat.

Vocabulare

Vocabularele sunt listele de codificare, cunoscute si sub numele de nomenclatoare. In HL7 poarta numele de sisteme de codificare (coding system).

O valoare dintr-un vocabular este identificata unic cu ajutorul a doua informatii: codingSystem = un cod care identifica unic vocabularul – aceste coduri sunt asignate de catre HL7 si se numesc OID-uri code = un cod care identifica unic valoarea din vocabular

Optional, pot fi prezentate si informatii privind: codeSystemName = numele vocabularului

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displayName = numele valorii din vocabular

Lista vocabularelor, impreuna cu elementele unde sunt folosite sunt prezentate mai jos:

Vocabulare generice:vocabular (CodeSystem) elemente codificate in CDAAdministrativeGender (codeSystem="2.16.840.1.113883.5.1")

administrativeGenderCode

Confidentiality (codeSystem="2.16.840.1.113883.5.25")

confidentialityCode

LOINC (codeSystem="2.16.840.1.113883.6.1")

section.code

ParticipationFunction (codeSystem="2.16.840.1.113883.5.88")

section.entry.procedure.participant.participantRole.code

SNOMED CT (codeSystem="2.16.840.1.113883.6.96")

section.entry.observation.code

ActStatus section.entry.procedure.statusCodesection.entry.observation.statusCode

Entitati

Entitatile sunt obiecte din lumea reala (persoane, sectii, etc), care trebuie identificate unic, dar care nu fac parte dintr-un vocabular predefinit deoarece sunt create de o anumita institutie.Exemple de entitatile in acceptiunea HL7 sunt: organizatiile, persoanele, departamentele, etc.

O entitate este identificata unic cu ajutorul a doua informatii: root = un cod care identifica unic tipul identificatorului entitatii extension = un identificator unic generat de catre institutia care l-a creat

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CDA – Sectiuni din header

Clinical Document

DescriereSectiunea ClinicalDocument include date de audit care ofera informatii detaliate privind crearea documentului.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

ClinicalDocument.id rootextension

II M: 1..1 Tipul idului unic al documentuluiGUID generat de aplicatia ce l-a creat poate fi folosit la relationarea documentelor

ClinicalDocument.code codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 tipul documentului

ClinicalDocument.title ST M: 0..1 titlul documentuluiClinicalDocument.effectiveTime

value TS M: 1..1 data cand a fost creat documentul (DateTime)

ClinicalDocument.confidentialityCode

codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 nivelul de confidentialitate al documentului

ClinicalDocument.setId rootextension

II M: 0..1 un identificator care identifica (grupeaza) toate versiunile respectivului document

ClinicalDocument.versionNumber

value INT M: 0..1 o valoare intreaga folosita pentru versionarea succesiva a documentului

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Exemplu

<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns="urn:hl7-org:v3"> <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" /> <id root="InfoWorld" extension="633c0c85-f028-49d7-a336-68f73c719b74" /> <code codeSystemName="LOINC" code="34764-1" codeSystem="2.16.840.1.113883.6.1" displayName="Consultatie boli interne"/> <title>Consultatie boli interne</title> <effectiveTime value="20080124100540.3505+02" /> <confidentialityCode code="N" displayName="Normala" codeSystem="2.16.840.1.113883.5.25" codingSchemeName=”confidentiality”/> <setId root="InfoWorld" extension="PA0076" /> <versionNumber value="1" />

Record Target

DescriereSectiunea RecordTarget contine informatiile despre pacient, care include mecanismul de identificare a pacientului, caracteristicile pacientului, numele lui, adresa si numarul de telefon.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

recordTarget.patientRole.id

rootextension

II R: 1..* Identificator unic al unui pacient; Pentru aflarea tipului identificatorului se foloseste atributul root de exemplu: CNP, idAsigurat

recordTarget.patientRole.patient.id [Deprecated]

rootextension

II R: 1..* Identificator unic al unui pacient; Pentru aflarea tipului identificatorului se foloseste atributul root de exemplu: CNP, idAsigurat

recordTarget.patientRole.patient.name

PN R: 0..* Numele pacientului

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recordTarget.patientRole.patient.administrativeGenderCode

CodecodeSystemcodeSystemNamedisplayName

CE R: 0..1 sexul pacientului

recordTarget.patient.patient.birthTime

value TS R: 0..1 data nasterii pacientului

Exemplu

<recordTarget> <patientRole> <id root="InfoWorld" extension="993c5721-803f-4dfa-b2b6-592190927931" /> <patient> <id root="InfoWorld" extension="993c5721-803f-4dfa-b2b6-592190927931" /> <name> <given>POPESCU</given> <family>IONELA</family> </name> <administrativeGenderCode displayName="Feminin" code="F" codeSystem="2.16.840.1.113883.5.1" CodeSystemName="AdministrativeGender"/> <birthTime value="19831207000000.0000+02" /> </patient> </patientRole> </recordTarget>

Author

DescriereSectiunea Author ofera informatii demografice privind creatorul (trimitatorul) documentului, de exemplu medicul care are in grija pacientul. Un document CDA nu poate fi editat si trimis mai departe cu numele unui autor anterior al respectivului document. Autor va fi intotdeauna persoana care a editat ultima respectivul document. Informatiile din aceasta sectiune descriu de asemenea sistemul informatic care a generat documentul CDA.

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Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

author.time value TS M: 1..1 data si timpul cand a fost creat documentulauthor.assignedAuthor.id root

extensionII M: 1..* identificarea utilizatorului/persoanei care a generat respectivul

documentAuthor.assignedAuthor.assignedPerson.name

PN O:0..* Numele persoanei care a generat respectivul document (momentan se ia din hm consultantul asociat utilizatorului logat in HM)

author.assignedAuthor. assignedAuthoringDevice.softwareName

ST O: 0..1 numele aplicatiei care a generat documentul

author.assignedAuthor.representedOrganization.id

rootextensionassigningAuthorityName

II O: 0..1 identificatorul organizatiei in care a fost generat documentul

author.assignedAuthor.representedOrganization.name

ON O: 0..1 numele organizatiei in care a fost generat documentul

Exemplu

<author> <time value="20080124100540.3192" /> <assignedAuthor> <id root="softinfo" extension="mircean" /> <assignedPerson> <name> <family>Test</family> <given>Test</given> </name> </assignedPerson>

<assignedAuthoringDevice> <softwareName>Laboratory Data Exchange Solution</softwareName>

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</assignedAuthoringDevice> <representedOrganization> <id root="InfoWorld" extension="00000000-0000-0000-0000-000000000000" assigningAuthorityName="medcenter "/>

<name> Emergency Laboratory </name> </representedOrganization> </assignedAuthor> </author>

Custodian

DescriereSectiunea Custodian reprezinta organizatia care a generat documentul si care este responsabila de mentinerea lui. Aceasta este si organizatia care a trimis respectivul document.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

custodian.assignedCustodian.representedCustodianOrganization.id

rootextension

II M: 1..* identificatorul custodianului respectivului documentCustodianul este responsabil de gestionarea documentului

custodian.assignedCustodian.representedCustodianOrganization.name

ON O: 0..1 numele custodianului respectivului documentCustodianul este responsabil de gestionarea documentului

Exemplu

<custodian> <assignedCustodian> <representedCustodianOrganization> <id root="InfoWorld" extension="00000000-0000-0000-0000-000000000000" /> </representedCustodianOrganization>

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</assignedCustodian> </custodian>

Informatiile destinatarului

Descriere

Aceasta sectiune contine informatii despre entitatea care primeste documentul.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

informationRecipient typeCode Un cod care specifica tipul de receptor al documentului (daca e destinatarul primar sau unul secundar)

informationRecipient. intendedRecipient

classCode Un cod care specifica tipurile de organizatii pentru organizatia care primeste documentul

informationRecipient.intendedRecipient.receivedOrganization.id

RootExtensionAssigningAuthorityName

II O: 0..1 Id-ul organizatiei care primeste documetnul

informationRecipient.intendedRecipient.receivedOrganization.name

ON O: 0..1 Numele organizatiei la care ajunge documentul

informationRecipient.intendedRecipient.informationRecipient

O:0..1 Daca trimiterea se face catre o anumita persoana, numele acesteia se precizeaza in informationRecipient.intendedRecipient.informationRecipient.name

informationRecipient. code CE O:0..1 Tipul cabinetului caruia ii este destinat documentul (folosit in cazul

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intendedRecipient. receivedOrganization. asOrganizationPartOf.code

codeSystemcodeSystemNamedisplayName

trimiterilor, pentru a specifica specialitatea la care se face trimiterea)

Exemplu

<informationRecipient typeCode="PRCP"> <intendedRecipient classCode="ASSIGNED"> <receivedOrganization> <id root="2.16.840.1.113883.5.10588" extension="LAB" assigningAuthorityName="Medcenter" /> <name> Emergency Laboratory </name> </receivedOrganization> </intendedRecipient> </informationRecipient>

sau

<informationRecipient typeCode="PRCP"> <intendedRecipient classCode="ASSIGNED"> <informationRecipient> <name> <family>Dobre</family> <given>Daniel</given> </name> </informationRecipient> <receivedOrganization> <asOrganizationPartOf> <code displayName="Cardiologie" codeSystemName="SpecialitatiMedicale " code="4" codeSystem="10.10.10.40" /> <wholeOrganization> <name>Spitalul Clinic Caritas – Acad.N.Cajal</name> <addr> <city>Bucuresti</city> </addr> </wholeOrganization> </asOrganizationPartOf> </receivedOrganization> </intendedRecipient></informationRecipient>

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Participant

Descriere

Sectiunea Participant contine date despre medicul curant

Elemente si atributeElemente Atribute Tip data R/M/O:

cardinalitateDescriere

Participant typeCode Tipul participantului (Relatia participantului cu pacientul)Participant.time value IVL<TS> O: 0..1 Intervalul de timp in care a avut rolul de participant.Participant.asociatedEntity.id

II O: 0..* ID-ul participantului

Participant.asociatedEntity

classCode Tipul entitatii: persoana sau organizatie.

Participant.asociatedEntityAssociatedPerson.name

PN O: 0..1 Numele participantului

Exemplu

<participant typeCode="ATND"> <time> <low value="20080122164900.9200+02" /> </time> <associatedEntity classCode="PRS"> <id root="InfoWorld" extension="0D66128F-0200-4572-9366-923F826652FD" /> <associatedPerson> <name> <given>DRAGOS</given> <family>GEORGESCU</family>

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</name> </associatedPerson> </associatedEntity> </participant>

inFulfillmentOf

Descriere

Sectiunea inFulfillmentOf contine date despre alte documente pentru care a fost generat documentul curent

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

inFulfillmentOf type Tipul legaturii dintre documente (ActRelationship)inFulfillmentOf typeCode Un cod care specifica motivul legaturii (FLFS)inFulfillmentOf.priorOrder

TypeclassCodemoodCode

inFulfillmentOf.priorOrder.id

RootExtension

II M:1..* ID-ul documentului pentru care a fost generat documentul curent

Exemplu

<inFulfillmentOf type="ActRelationship" typeCode="FLFS"><priorOrder type="ActHeir" classCode="ACT" moodCode="RQO">

<id extension="122507" root = ""/>

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</priorOrder></inFulfillmentOf>

relatedDocument

Descriere

Sectiunea relatedDocument contine date despre versiunile anterioare ale documentului curent

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

relatedDocument typeCode Un cod care specifica relatia dontre versiunea curenta si cea anterioara.

A conformant CDA document can have: a single relatedDocument with typeCode "APND"; a single relatedDocument with typeCode "RPLC"; a single relatedDocument with typeCode "XFRM"; a combination of two relatedDocuments with typeCodes

"XFRM" and "RPLC"; or a combination of two relatedDocuments with typeCodes

"XFRM" and "APND". No other combinations are allowed.

relatedDocument.parentDocument.id

RootExtension

II R:1..* ID-ul versiunii anterioare a documentului

relatedDocument.parentDocument.setId

RootExtension

II R:0..1 ID-ul setului de versiuni de documente

relatedDocument.parentDocument.versionNumber

Value INT R:0..1 Numarul versiunii anterioare

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Exemplu

<relatedDocument type="ActRelationship" typeCode="RPLC"><parentDocument>

<id root="InfoWorld" extension="122507v7_57027_O" /><setId root="InfoWorld" extension="122507" /><versionNumber value="7" />

</parentDocument></relatedDocument>

Component Of

DescriereAceasta sectiune reprezinta informatiile privind actul medical (numit "encounter" in HL7) pe durata caruia s-au efectuat serviciile medicale si a fost creat/generat respectivul document.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

encompassingEncounter.id

rootextension

II O: 0..* id unic al encounterului. GUID generat de aplicatia ce a creat documentulAlte id-uri posibile: numar registru de consultatii, codul de prezentare

encompassingEncounter.code

codecodesystemdisplayNamecodeSystemName

CE O:0..1 Codul tipului de encounter (IMP pentru internari, AMB pentru consultatii in ambulator)

encompassingEncounter.effectiveTime.Low

TS M: 1..1 data de inceput a encounterului

encompassingEncounter.effectiveTime.High

TS M: 1..1 data de sfarsit a encounterului

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encompassingEncounter.encounterParticipant

typeCode="ATND" sau alt tip de medic

II M: 1..1 tipul medicului (relatia medicului cu pacientul pe acest encounter) (de obicei se trec doua inregistrari aici, medicul currant si medicul trimitator)

encompassingEncounter.encounterParticipant.assignetEntity.id

Rootextension

II M: 1..* Unul sau mai multe id-uri ale medicului de pe encounter(id-ul medicului in aplicatie, codul de parafa etc)

encompassingEncounter.encounterParticipant.assignetEntity.assignedPerson.name

PN O:1..1 Numele medicului de pe encounter

encompassingEncounter.encounterParticipant.assignetEntity.code

CE O:0..1 Tipul participantului la encounter. Pentru medici este „healthcare provider” (furnizor de servicii medicale)

encompassingEncounter.encounterParticipant.assignetEntity.code. qualifier

CR O:0..* Mai multe detalii despre medic ca furnizor de servicii medicale. Momentan sunt folosite 2 feluri de detalii: casa de asigurari cu care are contract si specialitatea medicului. Specialitatea poate avea si ea un qualifier, gradul profesional.

encompassingEncounter.encounterParticipant.assignetEntity. representedOrganization

O:0..1 In cazul medicului trimitator, se poate completa si unitatea trimitatoare.

encompassingEncounter.encounterParticipant.assignetEntity. representedOrganization.id

Rootextension

II O:0..* id-uri ale unitatii medicale trimitatoareex: id-ul intern al aplicatiei , id-ul alocat de casa de asigurari (nr de contract in acest caz)

encompassingEncounter.encounterParticipant.assignetEntity. representedOrganization.name

ON O:0..* Numele unitatii medicale trimitatoare

encompassingEncounter.location.healthCareFacility.serviceProviderOrganization.id

Rootextension

II O: 0..* ID cabinetului in care a avut loc encounterul

encompassingEncounter O:0..1 Numele cabinetului in care a avut loc encounterul

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.location.healthCareFacility.serviceProviderOrganization.nameencompassingEncounter.location.healthCareFacility.serviceProviderOrganization.asOrganizationPartOf.wholeOrganization.id

Rootextension

II O: 0..* Id-ul organizatiei unde a avut loc encounterul

encompassingEncounter.location.healthCareFacility.serviceProviderOrganization.asOrganizationPartOf.wholeOrganization.name

ON O:0..1 Numele organizatiei unde a avut loc encounterul

Exemplu

<componentOf> <encompassingEncounter> <id root="InternalID" extension="c438ad47-3e63-47ed-82ed-4bdeb0514031" /> <code code="AMB" displayName="Ambulatory" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/> <effectiveTime> <low value="20080122164900.9200+02" /> </effectiveTime> <encounterParticipant typeCode="ATND"> <time> <low value="20080122164900.9200+02" /> </time> <assignedEntity> <id root="InfoWorld" extension="0D66128F-0200-4572-9366-923F826652FD" />

<id root="Cod-parafa" extension="123456" /> <assignedPerson> <name> <given>DRAGOS</given> <family>GEORGESCU</family>

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</name> </assignedPerson> </assignedEntity> </encounterParticipant> <encounterParticipant typeCode="REF"> <time> <low value="20080122000000.0000+02" /> </time> <assignedEntity> <id root="InfoWorld" extension="400C1F62-5AA5-4CB3-8B81-D9D325C8983F" />

<id root="Cod-parafa" extension="000864" /> <code displayName="furnizor de servicii medicale" codeSystemName="RoleClass" code="PROV" codeSystem="2.16.840.1.113883.5.110"> <qualifier> <name displayName="specialitate medicala" codeSystemName="SNOMED Clinical Terms" code="394658006" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Cardiologie" codeSystemName="SpecialitatiMedicale" code="4" codeSystem="10.10.10.10.40" /> </qualifier> <qualifier> <name displayName="casa de asigurari" codeSystemName="RoleClass" code="UNDWRT" codeSystem="2.16.840.1.113883.5.110" /> <value displayName="CASA OPSNAJ" codeSystemName="InsuranceHouse" code="OPSNAJ" codeSystem="3.3.3.3.90" /> </qualifier>

</code> <assignedPerson> <name> <given>MIRELA</given> <family>ANGHEL</family> </name> </assignedPerson> </assignedEntity> <representedOrganization> <id root="Nr-contract-casa" extension="A-59" assigningAuthorityName="CASA OPSNAJ" /> <name> SC TELEMEDICA SA</name> </representedOrganization> </encounterParticipant> <location> <healthCareFacility> <serviceProviderOrganization> <id root="InfoWorld" extension="388C2A6F-5F88-4B3C-BD75-B4047F16A963" /> <name>ECOGRAFIE</name> <asOrganizationPartOf> <wholeOrganization> <id root="InfoWorld" extension="5831507D-7158-47AC-A416-20029D861E98" /> <name>Medcenter Berceni</name> </wholeOrganization> </asOrganizationPartOf> </serviceProviderOrganization>

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</healthCareFacility> </location> </encompassingEncounter> </componentOf>

CDA – Sectiuni din body

Billing

Descriere

Aceasta sectiune contine modul in care se platesc consultatiile si numele pacientului.Referinta: http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

Component.section templateID=”1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7”

M: 1..1

Component.section.code CodeDisplayNameCodeSystemCodeSystemName

CE M 1..1 Cod in care se specifica tipul sectiunii („Payment Sources” din LOINC)<code displayName="Contract" codeSystemName="LOINC" code="48768-6" codeSystem="2.16.840.1.113883.6.1" />

Component.section.entry.act

classCodemoodCode

M: 1..1 Inregistrarea contine detalii despre modalitatea de intelegere pentru plata, in cazul de fata contractul

Component.section.entry.act.templateID

M: 1..1 Doua id-uri de templateuri din standardul IHE, care se salveaza asa cum sunt.

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<templateId root="2.16.840.1.113883.10.20.1.26" /> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.18" />

Component.section.entry.act.id

Rootextension

II M: 1..1 Id-ul contractului

Component.section.entry.act.code

CodeDisplayNameCodeSystemCodeSystemName

CE M: 1..1 Codul tipului de plata pentru contractul respectiv. Momentan e hardcodat pe pacient, dar probabil ca ar putea avea si alte valori. Eventual s-ar putea salva chiar accountType-ul de pe contract

Component.section.entry.act.performer.assignedEntity.id

rootextension

II M: 1..1 ID-ul organizatiei platitoare

Component.section.entry.act.performer.assignedEntity.code

CodeDisplayNameCodeSystemCodeSystemName

CE M: 1..1 Codul care reprezinta tipul de entitate care plateste (organizatia, pacientul, etc)

Component.section.entry.act.performer.assignedEntity.representedOrganization.name

TEXT O: 1..1 Numele entitatii platitoare

Component.section.entry.act.participant.participantRole

classCode O:0..1 Participantul (pacientul)

Component.section.entry.act.participant.participantRole.code

CodeDisplayNameCodeSystemCodeSystemName

CE R: 1..1 Un cod ce semnifica relatia pacientului cu contractual/entitatea platitoare. Poate avea doua valori (asigurat/abonat sau dependent)

Component.section.entry.act.participant.participantRole.Id

RootExtension

II O:1..1 Identificatorul participantului (pacientului) in relatia cu organizatia platitoare

Component.section.entry.act.participant.participantRole.playingEntity.name

TEXT O: 1..1 Numele participantului (pacientului)

Component.section.entry.act.entryRelationship.act

Aici se specifica detalii despre contract

Component.section.entry.act.entryRelationship.act.id

RootExtension

II M: 1..1 Id-ul contractului

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Component.section.entry.act.entryRelationship.act.text.reference

TEXT O 1..1 Numele/denumirea contractului

Component.section.entry.act.entryRelationship.act.code

CodeDisplayNameCodeSystemCodeSystemName

CD O: 0..1 Categoria de asiguratValueSet: HM3PersonState

Component.section.entry.act.entryRelationship.act.code.qualifier

NameValue

CR O: 0..1 Numar PNSValueSet:HM3NHP<name displayName="PNS" codeSystemName="SNOMED CT" code="iw-pns" codeSystem="2.16.840.1.113883.6.96" />

Component.section.entry.act.entryRelationship.act. entryRelationship.act.code

CodeDisplayNameCodeSystemCodeSystemName

CD O: 0..1 Pachetul de serviciiValueSet: HM3MedSrvPackage

Exemplu <component> <section xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns="urn:hl7-org:v3"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.5.3.7" /> <code displayName="Contract" codeSystemName="LOINC" code="48768-6" codeSystem="2.16.840.1.113883.6.1" /> <entry> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.26" /> <templateId root="2.16.840.1.113883.10.20.1.26" /> <id root="Contract-id" extension="39E4E234-2E15-4A26-B422-B14716AC06AF" /> <code displayName="Pacient" codeSystemName="AccountType" code="PA" codeSystem="100.100.100.3" /> <statusCode code="completed" /> <performer> <assignedEntity> <id root="InfoWorld" extension="dce79899-ddfc-4edb-a940-f39f5b831a5a" /> <code displayName="Pacient" codeSystemName="RoleClass" code="PAT" codeSystem="2.16.840.1.113883.5.110" /> </assignedEntity> </performer> <participant typeCode="COV" contextControlCode="AN"> <participantRole classCode="PAT">

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<id root="InfoWorld" extension="dce79899-ddfc-4edb-a940-f39f5b831a5a" /> <code displayName="subscriber" codeSystemName="RoleCode" code="SUBSCR" codeSystem="2.16.840.1.113883.5.111" /> <playingEntity> <name> <given partType="GIV">INT</given> <family partType="FAM">PAC</family> </name> </playingEntity> </participantRole> </participant> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="DEF"> <id root="Contract-id" extension="39E4E234-2E15-4A26-B422-B14716AC06AF" /> <code displayName="Alte categorii" codeSystemName="HM3PersonState" code="ALTE" codeSystem="3.3.3.3.107"> <qualifier> <name displayName="PNS" codeSystemName="SNOMED CT" code="iw-pns" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Tratamentul bolnavilor cu mucoviscidoza - adulti" codeSystemName="HM3NHP" code="12" codeSystem="3.3.3.3.10" /> </qualifier> </code> <text>SPITALIZARE</text> <entryRelationship typeCode="XCRPT"> <act classCode="ACT" moodCode="DEF"> <code displayName="PACHET MINIMAL" codeSystemName="HM3MedSrvPackage" code="MINIMAL" codeSystem="3.3.3.3.114" /> </act> </entryRelationship> </act> </entryRelationship> </act> </entry> </section>

</component>

Istoric afectiuni

Cardinalitate0..*

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Descriere

Aceasta sectiune contine detalii despre istoricul afectiunilor, diagnosticelor, medicatiei pacientului.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

Component.section.code codeSystemcodeSystemNamecodedisplayName

CE M:1..1 Aici se specifica tipul sectiunii:<code codeSystemName="LOINC" code="10153-2" displayName="Clinical History" codeSystem="2.16.840.1.113883.6.1" />

Component.section.title TEXT Titlul sectiuniiComponent.section.text TEXT Folosit pentru a introduce datele acestei sectiuni Component.section.entry.observation

classCode

Component.section.entry.observation.code

codecodedisplayNamecodeSystemcodeSystemName

CE O:0..1 Antecedent (diagnostic)

Component.section.entry.observation.code.Qualifier.name

codecodedisplayNamecodeSystemcodeSystemName

CE O:0..1 Apare in cazul existentei unui diagnostic secundar. Aici se specifica faptul ca acest qualifier se refera la un diagnostic secundar:<name displayName="Secondary diagnosis" codeSystemName="SNOMED CT" code="85097005" codeSystem="2.16.840.1.113883.6.96" />

Component.section.entry.observation.code.Qualifier.value

codecodedisplayNamecodeSystemcodeSystemName

CE O:0..1 Apare in cazul existentei unui diagnostic secundar. Aici se specifica diagnosticul secundar

Component.section.entry.observation.code.Qualifier.name

codecodeDisplayNamecodeSystemcodeSystemName

CE R:0..1 Aici se specifica faptul ca acest qualifier se refera la tipul de antecedent:<name displayName="Antecedent type" codeSystemName="LOINC" code="70000-9"

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codeSystem="2.16.840.1.113883.6.1" />Component.section.entry.observation.code.Qualifier.value

codecodeDisplayNamecodeSystemcodeSystemName

CE R:0..1 Aici se specifica tipul de antecedent (congenital, patologic, fiziologic).ValueSets: HM3AntecedentTypeChild (se foloseste pt Fisa consultatie copil); HM3AntecedentTypeAdult (adulti)

Component.section.entry.observation.text

TEXT O:0..1 Comentarii asociate diagnosticului secundar.

Component.section.entry.observation.effectiveTime

value TS R:0..1 Data stabilirii diagnosticului respectiv

Component.section.entry.observation. entryRelationship.observation.code

codecodeDisplayNamecodeSystemcodeSystemName

CE O:0..1 <code displayName="Data rezolvare" codeSystemName="SNOMED CT" code="413947000" codeSystem="2.16.840.1.113883.6.96" />

Component.section.entry.observation. entryRelationship.observation.text

TEXT O:0..1 Data rezolvarii

Component.section.entry.observation.targetSiteCode

codedisplayNameCodeSystemCodeSystemName

CE O:0..1 Codul zonei corpului care este examinata

Component.section.entry.observation.targetSiteCode.qualifier.name

displayNamecodeSystemNamecodecodeSystem

In cazul in care zona corpului are si alte atribute (de exemplu lateralitate) atunci aici se trec informatii despre tipul atributului

Component.section.entry.observation.targetSiteCode.qualifier.value

displayNamecodecodeSystemcodeSystemName

In cazul in care zona corpului are si alte atribute (de exemplu lateralitate) atunci aici se trec informatii despre valoarea atributului

Exemplu

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<component><section>

<code codeSystemName="LOINC" code="10153-2" displayName="Clinical History" codeSystem="2.16.840.1.113883.6.1" /><title>Istoric afectiuni</title><text>

<list><item>

<paragraph>Diagnostic: Hipertensiunea esentiala (primara)</paragraph><paragraph>Vârstă diagnosticare: 18 ani</paragraph>

</item><item>

<paragraph>Diagnostic: Insuficienta venoasa (cronica) (periferica)</paragraph><paragraph>Vârstă diagnosticare: 20 ani</paragraph>

</item></list>

</text><entry>

<observation classCode="COND"><code displayName="Hipertensiunea esentiala (primara)" code="I10" codeSystem="2.16.840.1.113883.6.135"

codeSystemName="IC10AM"><qualifier>

<name displayName="Secondary diagnosis" codeSystemName="SNOMED CT" code="85097005" codeSystem="2.16.840.1.113883.6.96" />

<value displayName="Accident al unei ambarcatiuni provocand alte raniri, ambarcatiune nespecificata" codeSystemName="ICD10AM" code="V91.9" codeSystem="2.16.840.1.113883.6.135" />

</qualifier><qualifier>

<name displayName="Antecedent type" codeSystemName="LOINC" code="70000-9" codeSystem="2.16.840.1.113883.6.1" />

<value displayName="Congenital | Patologic | Fiziologic" codeSystemName=" " code=" " codeSystem="" />

</qualifier>

</code><statusCode /><effectiveTime value="20020123000000.0000+02" /><targetSiteCode displayName="Structura cardiovasculara" code="113257007"

codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED Clinical Terms"/></observation>

</entry><entry>

<observation classCode="COND"><code displayName="Insuficienta venoasa (cronica) (periferica)" code="I87.2"

codeSystem="2.16.840.1.113883.6.135" /><statusCode /><effectiveTime value="20040714000000.0000+02" />

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<targetSiteCode displayName="Intregul compartiment al membrelor inferioare" code="276744008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED Clinical Terms">

<qualifier><name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007"

codeSystem="2.16.840.1.113883.6.96" /><value displayName=" Anterior stanga" code=" 264065008"

codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /></qualifier>

</targetSiteCode></observation>

</entry></section>

</component>

Narativ

<text><list>

<item><paragraph>Diagnostic: Botulismul</paragraph><paragraph>Vârstă diagnosticare: 0 ani</paragraph><paragraph>Vârstă rezolvare: 0 ani</paragraph>

</item><item>

<paragraph>Diagnostic: Infarct miocardic acut</paragraph><paragraph>Vârstă diagnosticare: 0 ani</paragraph><paragraph>Vârstă rezolvare: 0 ani</paragraph>

</item></list>

</text>

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Semne vitale

Cardinalitate

0..1

DescriereAceasta sectiune documenteaza – daca este cazul – greutatea, inaltimea si alte semne vitale ale pacientului.

Elemente si atributeElemente Atribute Tip data R/M/O: cardinalitate Descriere

Component.section.codecode codeSystemcodeSystemNamedisplayName

CE M: 1..1 codul sectiunii de Semne vitale:<code codeSystemName="LOINC" code="8716-3" codeSystem="2.16.840.1.113883.6.1" displayName=”VitalSigns”/>

component.section.title TEXT Titlul sectiunii component.section.text TEXT Campul care este folosit pentru a afisa detaliile

acestei sectiuni in format text, pentru vizualizari section.entry.observation classCode

moodCodeR: 1..* cate un astfel de element pentru fiecare semn vital

section.entry.observation.code

CodeDisplayNamecodeSystemcodeSystemName

CE M: 1..1 tipul semnului vital

section.entry.observation.value

xsi:typeunitvalue

PQ,RTO_PQ_PQ

M: 1..1 Tipul de data pentru valoare si valoarea semnului vital

component.sectio value IVL_TS O: 0..1 Data in care s-au executat masuratorile

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n.entry.observation.effectiveTime

Exemplu

<component> <section> <code codeSystemName="LOINC" code="8716-3" codeSystem="2.16.840.1.113883.6.1" displayName=”VitalSigns”/> <title>Semne Vitale</title> <text> <table> <tbody> <tr> <th>Dată / Oră</th> <th>22.01.2008 09:15:00</th> <th>24.01.2008 10:16:52</th> </tr> <tr> <th>Înălţime</th> <td align="center">165 Cm</td> <td align="center">165 Cm</td> </tr> <tr> <th>Greutate</th> <td align="center">61 Kg</td> <td align="center">60 Kg</td> </tr> <tr> <th>IMC</th> <td align="center">22,41 Kg/Cm2</td> <td align="center">22,04 Kg/Cm2</td> </tr> <tr> <th>ISC</th> <td align="center">0,17 Cm2</td> <td align="center">0,17 Cm2</td> </tr> <tr> <th>Temperatură</th>

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<td align="center">37,4 Grade C</td> <td align="center">37 Grade C</td> </tr> <tr> <th>Puls</th> <td align="center">85 / min</td> <td align="center">82 / min</td> </tr> <tr> <th>Ritm cardiac</th> <td align="center">Tahicardie</td> <td align="center">Puls neregulat</td> </tr> <tr> <th>Respiraţie</th> <td align="center">23 / min</td> <td align="center">21 / min</td> </tr> <tr> <th>Sistolică</th> <td align="center">160 mm[Hg]</td> <td align="center">148 mm[Hg]</td> </tr> <tr> <th>Diastolică</th> <td align="center">90 mm[Hg]</td> <td align="center">80 mm[Hg]</td> </tr> <tr> <th>Poziţie manşeta</th> <td align="center">Bratul drept</td> <td align="center">Bratul drept</td> </tr> </tbody> </table> </text> <entry> <observation> <code displayName="Body height measure" codeSystemName="SNOMED CT" code="50373000" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="Cm" value="165" /> </observation> </entry> <entry> <observation> <code displayName="Body weight measure" codeSystemName="SNOMED CT" code="363808001" codeSystem="2.16.840.1.113883.6.96" />

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<statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="Kg" value="61" /> </observation> </entry> <entry> <observation> <code displayName="Body mass index" codeSystemName="SNOMED CT" code="60621009" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="22,41" unit="Kg" /> <denominator value="1" unit="m2" /> </value> </observation> </entry> <entry> <observation> <code displayName="Body surface area" codeSystemName="SNOMED CT" code="301898006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" value="0,17" unit="m2" /> </observation> </entry> <entry> <observation> <code displayName="Body temperature" codeSystemName="SNOMED CT" code="386725007" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="Grade C" value="37,4" /> </observation> </entry> <entry> <observation> <code displayName="Heart rate" codeSystemName="SNOMED CT" code="364075005" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="85" /> <denominator unit="min" value="1" /> </value> </observation> </entry> <entry> <observation> <code displayName="Respiratory rate" codeSystemName="SNOMED CT" code="86290005" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" />

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<effectiveTime value="20080122091500.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="23" /> <denominator unit="min" value="1" /> </value> </observation> </entry> <entry> <observation> <code displayName="Regularity of heart rhythm" codeSystemName="SNOMED CT" code="364074009" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="CD" displayName="Tahicardie" code="3424008" codeSystem="2.16.840.1.113883.6.96" /> </observation> </entry> <entry> <observation> <code displayName="Cuff blood pressure" codeSystemName="SNOMED CT" code="251076008" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <targetSiteCode displayName="Bratul drept" code="368209003" codeSystem="2.16.840.1.113883.6.96" /> <entryRelationship typeCode="COMP"> <observation> <code displayName="Systolic BP" codeSystemName="SNOMED CT" code="271649006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="mm[Hg]" value="160" /> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation> <code displayName="Diastolic BP" codeSystemName="SNOMED CT" code="271650006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="mm[Hg]" value="90" /> </observation> </entryRelationship> </observation> </entry> </section></component>

Narativ

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<text><table>

<tbody><tr>

<th>Dată / Oră</th><th>21.05.2009 15:16:38</th><th>21.05.2009 15:18:43</th>

</tr><tr>

<th>Înălţime</th><td align="center">178 Cm</td><td align="center">178 Cm</td>

</tr><tr>

<th>Greutate</th><td align="center">100 Kg</td><td align="center">100 Kg</td>

</tr><tr>

<th>IMC</th><td align="center">31,56 Kg/m2</td><td align="center">31,56 Kg/m2</td>

</tr><tr>

<th>ISC</th><td align="center">2,22 m2</td><td align="center">2,22 m2</td>

</tr><tr>

<th>Temperatură</th><td align="center">36,8 Grade C</td><td align="center">36,9 Grade C</td>

</tr><tr>

<th>Puls</th><td align="center">110 / min</td><td align="center">106 / min</td>

</tr><tr>

<th>Ritm cardiac</th><td align="center">Puls normal</td><td align="center">Puls normal</td>

</tr><tr>

<th>Respiraţie</th><td align="center">50 / min</td><td align="center">55 / min</td>

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</tr><tr>

<th>Sistolică</th><td align="center">12 mm[Hg]</td><td align="center">14 mm[Hg]</td>

</tr><tr>

<th>Diastolică</th><td align="center">8 mm[Hg]</td><td align="center">9 mm[Hg]</td>

</tr><tr>

<th>Poziţie manşeta</th><td align="center">Bratul drept</td><td align="center">Bratul stang</td>

</tr></tbody>

</table></text>

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Examen Clinic

Descriere

Aceasta sectiune contine date despre examenul clinic efectuat pacientului.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

Component.section.code code codeSystemcodeSystemNamedisplayName

CE M: 1..1 codul sectiunii:<code codeSystemName="LOINC" code="11384-5" displayName=“Physical Exam“ codeSystem="2.16.840.1.113883.6.1" />

component.section.title TEXT Titlul sectiunii Component.section.component.section

Cate o sectiune pentru fiecare sistem fizic examinat

Component.section.component.section.code

CodeCodeSystemcodeSystemNamedisplayName

CE M: 1..1 Codul sistemului fizic examinat

Component.section.component.section.title

TEXT O 1..1 Titlul sectiunii curente asociate sistemului fizic examinat

component.section.component.section.text

TEXT Campul care este folosit pentru a afisa datele din aceasta sectiune (un anumit sistem fizic examinat) intr-un format usor citibil

Component.section.component.section.entry.observation

negationInd Nu se mai folosesteAici se stocheaza o linie curenta dintr-o examinare a unui anumit sistem fizic. NegationInd e un flag care pentru anumite observatii are rolul de a marca lipsa unui comportament (simptom)

component.section.component.section.entry.observation.text

TEXT Observatiile care se fac in linia curenta din aceasta sectiune

component.section.comp Code M: 1..1 Starea observatiei curente

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onent.section.entry.observation.statusCodecomponent.section.componen.section.entry.observation.methodCode

displayNamecodecodeSystemcodeSystemName

CE M: 1..1 Metoda prin care s-a facut examinarea

component.section.component.section.entry.observation.targetSiteCode

displayNamecodecodeSystemcodeSystemName

CE M: 1..1 Zona corpului in care s-a facut examinarea

Component.section.component.section.entry.observation.targetSiteCode.qualifier.name

displayNamecodeSystemNamecodecodeSystem

CE O: 1..1 In cazul in care zona corpului are si alte atribute (de exemplu lateralitate) atunci aici se trec informatii despre tipul atributului

Component.section.entry.observation.targetSiteCode.qualifier.value

displayNamecodecodeSystemcodeSystemName

CE O: 1..1 In cazul in care zona corpului are si alte atribute (de exemplu lateralitate) atunci aici se trec informatii despre valoarea atributului

Exemplu

<component> <section> <code codeSystemName="LOINC" code="11384-5" displayName=“Physical Exam“ codeSystem="2.16.840.1.113883.6.1" /> <title>Examen clinic</title> <component> <section> <code displayName="Sistemul cardiovascular" code="11390-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Sistemul cardiovascular</title> <text> <list> <item> <paragraph>Ritm sinusal normal, Tahicardie bazala, Extrasistole ventriculare. a fost examinat folosind Auscultatie pe Regiunea cavitatii toracice Anterior.</paragraph> </item> </list> </text>

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<entry> <observation> <text>Ritm sinusal normal, Tahicardie bazala, Extrasistole ventriculare.</text> <statusCode code="completed" /> <methodCode displayName="Auscultatie" code="37931006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> <targetSiteCode displayName="Regiunea cavitatii toracice" code="281825004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" > <qualifier> <name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Anterior" code="255549009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> </qualifier> </targetSiteCode> </observation> </entry> </section> </component> <component> <section> <code displayName="Picior" code="11397-7" codeSystem="2.16.840.1.113883.6.1" /> <title>Picior</title> <text> <list> <item> <paragraph>Inflamatia vaselor periferice cu imobilitate partiala stanga. a fost examinat folosind Examinare digitala pe Intregul compartiment al piciorului inferior (sub genunchi) Stanga.</paragraph> </item> </list> </text> <entry> <observation> <text>Inflamatia vaselor periferice cu imobilitate partiala stanga.</text> <statusCode code="completed" /> <methodCode displayName="Examinare digitala" code="239033002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> <targetSiteCode displayName="Intregul compartiment al piciorului inferior (sub genunchi)" code="307040006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" > <qualifier> <name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Stanga" code="62372003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> </qualifier> </targetSiteCode> </observation> </entry> </section> </component> </section></component>

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Narativ

<text><list>

<item><paragraph>

<content>Observaţii clinice asupra sistemului examinat 'Abdomen':</content><content>

<br /></content><content>Stare normala, neinflamat</content>

</paragraph><paragraph>Metoda folosită: examinare digitala pe structura cavitatii toracice drepte median</paragraph>

</item></list>

</text>

Medicatie

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Descriere

Aceasta sectiune contine medicamentele prescrise, eliberate si curente. In viitor se va sparge in 3 sectiuni.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

Component.section.code codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 Codul care identifica sectiunea de prescriere medicamente:<code codeSystemName="LOINC" code="29305-0" displayName=”Medication Prescription” codeSystem="2.16.840.1.113883.6.1" />

Component.section.code.qualifier

NameValue

CR O:0..1 In cazul in care documentul este o reteta, se pot introduce aici detalii despre tipul retetei

Component.section.id RootExtension

II O:0..1 In cazul in care documentul este o reteta, se trece aici id-ul retetei.

component.section.title TEXT M: 1..1 Titlul sectiunii component.section.text TEXT M: 1..1 Campul care este folosit pentru a afisa datele introduse intr-o forma

usor citibilaComponent.section.entry.substanceAdministration

classCodemoodCode

O linie din prescriere. Prescriere medicamente: moodCode=’EVN’; (vezi anexa farmacie)cerere medicamente: moodCode=’RQO’;medicamente curente: moodCode=’INT’;

component.section.entry.substanceAdministration.text

TEXT O:0..1 Comentarii asociate liniei curente din prescriere

component.section.entry.substanceAdministration.effectiveTime.period

unitvalue

PIVL_TS

O:0..1 Frecventa cu care este recomandata administrarea medicamentului

component.section.entry.substanceAdministration.effectiveTime.low, high

value IVL_TS O:0..1 Data de inceput si data de sfarsit pentru administrarea medicamentului

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component.section.entry.substanceAdministration.approachSiteCode

codecodeSystemcodeSystemNamedisplayName

CE O:0..1 Partea corpului pe unde se va administra medicamentul

component.section.entry.substanceAdministration.routeCode

codecodeSystemcodeSystemNamedisplayName

CE O:0..1 Ruta de administrare a medicamentului

component.section.entry.substanceAdministration.doseQuantity

valueunit

IVL_PQ

O:0..1 Doza de medicamente prescrisa (de exemplu 2 pastile)

component.section.entry.substanceAdministration.rateQuantity.low,high

valueunit

PQ O:0..1 Rata de administrare a medicamentului (se foloseste mai mult ca un fel de debit de administrare in cazul lichidelor sa zicem... 5 ml pe ora)

component.section.entry.substanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.code

codecodeSystemcodeSystemNamedisplayName

CE O:0..1 Codul medicamentului prescris codeSystem = 100.100.100.5valueSet = Medicamente

component.section.entry.substanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.code.originalText

TEXT O:0..1 Aici se salveaza concentratia medicamentului (camp free text)

component.section.entry.substanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.code.qualifier

namevalue

CR O: 0..1 Se salveaza lista de pe care se prescrie medicamentul<name displayName="Lista medicamente" codeSystemName="SNOMED CT" code="iw-list" codeSystem="2.16.840.1.113883.6.96" />

component.section.entry substanceAdministration.entryRelationship.supply.quantity

value PQ O:0..1 Cantitatea de medicamente prescrisa (e un total pe linia curenta, folosit pentru order) (se exprima in aceeasi unitate de masura in care e exprimata doza)

component.section.entry substanceAdministration.re

Rootextension

II O:0..* Referinta catre un diagnostic din sectiunea de diagnostice

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ference.externalDocument.idcomponent.section.entry substanceAdministration.entryRelationship.observation.code

codecodeSystemcodeSystemNamedisplayName

CD O: 0..1 Categorie boala (entryRelationship.typeCode = RSON)

Note: In cazul in care nu este o prescriere de medicament ci este o administrare, sectiunea este similara doar ca are alt cod de sectiune (29303-

5) iar la moodCode-ul din substanceAdministration va aparea valoarea EVN In cazul in care este doar un order simplu fara prescriere, codul de sectiune e identic cu cel de la prescriere iar ca si campuri vor aparea

doar cele legate de numele medicamentului, cantitatea ceruta si unitatea de masura Informatii extinse despre implementare sunt in anexa Pharmacy.

Exemplu

<component><section>

<code codeSystemName="LOINC" code="29305-0" displayName="Medication Prescription" codeSystem="2.16.840.1.113883.6.1" /><title>Medicatie Prescriere</title><text>

<list><item>

<paragraph>ACESIL 250 unitati /gram pentru 96 ore</paragraph><paragraph>Cantitate cerută: 552 Grame</paragraph><paragraph>Doză: 2 Grame</paragraph><paragraph>Frecvenţă: 6/Zi</paragraph><paragraph>Calea de administrare: Epidurala</paragraph><paragraph>

<content>Comentarii: </content><content>comentarii</content>

</paragraph></item>

</list></text><entry>

<substanceAdministration classCode="SBADM" moodCode="RQO"><text>comentarii</text><effectiveTime xsi:type="PIVL_TS">

<period unit="D" value="6" />

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</effectiveTime><effectiveTime xsi:type="IVL_TS" operator="A">

<low value="20080201000000.0000+02" /><high value="20080205000000.0000+02" />

</effectiveTime><routeCode displayName="Epidurala" code="_EpiduralRoute" codeSystem="2.16.840.1.113883.5.112"

codeSystemName="RouteOfAdministration"/><approachSiteCode displayName="Antebratul inferior drept" code="RLFA"

codeSystem="2.16.840.1.113883.5.1052" codeSystemName="ActSite"/><doseQuantity unit="gr" value="2" /><rateQuantity>

<low unit="gr" value="3" /><high unit="HR" value="1" />

</rateQuantity><consumable typeCode="ADM">

<manufacturedProduct><manufacturedLabeledDrug>

<code displayName="ACESIL" code="W00077003" codeSystem="100.100.100.5" codeSystemName="Medicamente">

<qualifier><name displayName="Lista medicamente" codeSystemName="SNOMED CT"

code="iw-list" codeSystem="2.16.840.1.113883.6.96" /><value displayName="List A" code="A" />

</qualifier><originalText>250 unitati /gram</originalText>

</code></manufacturedLabeledDrug>

</manufacturedProduct></consumable><entryRelationship typeCode="COMP">

<supply moodCode="RQO"><statusCode code="new" /><repeatNumber /><independentInd value="false" /><quantity value="552" />

</supply></entryRelationship><entryRelationship typeCode="RSON">

<observation classCode="COND">><code codeSystemName=" HM3DiseaseCategory" code=" G11" displayName=" EPILEPSIE"

codeSystem="3.3.3.3.6"/></observation>

</entryRelationship><reference>

<externalDocument><id root="f165b09b-2358-4bd9-8743-111fef9da7b9" />

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</externalDocument></reference><reference>

<externalDocument><id root="332227b7-f692-4194-b848-f74d34a77e09" />

</externalDocument></reference>

</substanceAdministration></entry>

</section></component>

Sau

<section> <code codeSystemName="LOINC" code="29305-0" codeSystem="2.16.840.1.113883.6.1" /> <title>Medicatie prescrisa</title> <text> <paragraph>VIROLEX, 1 pastila la 3 zile</paragraph> </text> <entry> <substanceAdministration classCode="SBADM" moodCode="INT"> <effectiveTime xsi:type="PIVL_TS"> <period unit="zile" value="3" /> </effectiveTime> <consumable typeCode="ADM"> <manufacturedProduct> <manufacturedLabeledDrug> <code displayName="VIROLEX" codeSystemName="Medicamente" code="W00039001" codeSystem="100.100.100.5" /> </manufacturedLabeledDrug> </manufacturedProduct> </consumable> <entryRelationship typeCode="XCRPT"> <supply moodCode="INT"> <quantity unit="pastila" value="1" /> </supply> </entryRelationship> </substanceAdministration> </entry></section>

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Narativ

<text><list>

<item><paragraph>ACICLOVIR 5%</paragraph><paragraph>Cantitate cerută: 255 Capsule</paragraph><paragraph>Doză: 5 Capsule</paragraph><paragraph>Interval de administrare: o data la 12 ore pentru 5 zile</paragraph>

</item><item>

<paragraph>THIOGAMMA(R) 600 oral (vezi N07XN03)</paragraph><paragraph>Doză: 2 Capsule</paragraph><paragraph>Interval de administrare: o data la 12 ore pentru 5 zile</paragraph>

</item></list>

</text>

Diagnostice

Cardinalitate1..1

DescriereAceasta sectiune documenteaza diagnosticele ce au fost inregistrate pe respectiva foaie de observatie

Page 53: Ghid Implementare CDA

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

section.code code codeSystemcodeSystemNamedisplayName

CE M: 1..1 codul sectiunii de Diagnostice:<code codeSystemName="LOINC" code="11496-7" displayName=”Assessment” codeSystem="2.16.840.1.113883.6.1"/>

Section.title text M: 1..1 Titlul sectiuniiSection.text text R:1..1 Aici se introduc informatiile din sectiune puse intr-un format usor de

cititsection.entry.observation classCode R: 1..* cate un astfel de element pentru fiecare diagnostic codificatSection.entry.Observation.id

root II O: 1..1 Un Id folosit pentru a putea referi diagnosticul din alte sectiuni ale documentului (de exemplu din prescriere medicamente)

section.entry.observation.code

codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 tipul diagnosticului

section.entry.observation.code.qualifier.name

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care tipul diagnosticului are si alte atribute (de exemplu “has severity”) aici se salveaza numele atributului

section.entry.observation.code.qualifier.value

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care tipul diagnosticului are si alte atribute (de exemplu “has severity”) aici se salveaza valoarea atributului (acut, subacut, cronic)ValueSet: 3.3.3.3.96 – HM3MedicatieTipBoala

Section.entry.observation.text

TEXT

O: 0..1 Observatii asociate diagnosticului curent

section.entry.observation.statusCode

code CNE O: 0..1 se completeaza in CDA numai diagnosticele codificate pacientului

Section.entry.observation.effectiveTime

value TS O: 1..1 Data diagnosticului

section.entry.observation xsi:type CD M: 1..1 diagnosticul codificat

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.value codecodeSystemcodeSystemNamedisplayName

section.entry.observation.value.qualifier.name

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care diagnosticul are si alte atribute (de exemplu “Secondary diagnosis”) aici se salveaza numele atributului<code codeSystemName="SNOMED CT" code="85097005" displayName=”Secondary diagnosis” codeSystem="22.16.840.1.113883.6.96"/>

section.entry.observation.value.qualifier.value

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care diagnosticul are si alte atribute (de exemplu “Secondary diagnosis”) aici se salveaza valoarea atributului

section.entry.observation.targetSiteCode

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 Partea corpului unde este localizat diagnosticul

section.entry.observation.targetSiteCode.qualifier.name

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care targetSite are si alte atribute (de exemplu “with laterality”) aici se salveaza numele atributului

section.entry.observation.TargetSiteCode.qualifier.value

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care targetSite are si alte atribute (de exemplu “with laterality”) aici se salveaza valoarea atributului

Section.entry.observation.entryRelationship.observation.text

TEXT

O:0..1 Aici se salveaza eventualele recomandari pentru diagnosticul curent.

Exemplu

<component> <section> <code codeSystemName="LOINC" code="11496-7" displayName=”Assessment” codeSystem="2.16.840.1.113883.6.1"/>

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<title>Diagnostice</title> <text> <list> <item> <paragraph>Diagnostic: Hipertensiunea esentiala (primara)</paragraph> <paragraph>Vârstă diagnosticare: 24 ani</paragraph> </item> <item> <paragraph>Diagnostic: Insuficienta venoasa (cronica) (periferica)</paragraph> <paragraph>Vârstă diagnosticare: 24 ani</paragraph> </item> </list> </text> <entry> <observation classCode="COND"> <id root="d619611f-ee69-47f2-aa69-710fd90ae444" /> <code displayName="Diagnostic principal" code="8319008" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122000000.0000+02" /> <value xsi:type="CD" displayName="Hipertensiunea esentiala (primara)" code="I10" codeSystem="2.16.840.1.113883.6.135" /> <targetSiteCode displayName="Structura cardiovasculara" code="113257007" codeSystem="2.16.840.1.113883.6.96" /> </observation> </entry> <entry> <observation classCode="COND"> <id root="41dec706-e8ce-45c5-82e5-a6f0d70e57d1" /> <code displayName="Diagnostic clinic" code="39154008" codeSystem="2.16.840.1.113883.6.96"> <qualifier> <name displayName="Has severity" codeSystemName="SNOMED CT" code="43749003" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Moderat" code="6736007" codeSystem="2.16.840.1.113883.6.96" codeSystemName=”SNOMED CT”/> </qualifier> </code> <statusCode code="completed" /> <effectiveTime value="20080122000000.0000+02" /> <value xsi:type="CD" displayName="Insuficienta venoasa (cronica) (periferica)" code="I87.2" codeSystem="2.16.840.1.113883.6.135" codeSystemName=”ICD10AM”/> <targetSiteCode displayName="Intregul compartiment al membrelor inferioare" code="276744008" codeSystem="2.16.840.1.113883.6.96" codeSystemName=”SNOMED CT”> <qualifier> <name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Superficial" code="62372003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" /> </qualifier> </targetSiteCode> </observation> </entry> </section></component>

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Narativ<text>

<list><item>

<paragraph>Diagnostic principal: Giardiaza(lambliaza)</paragraph><paragraph>Vârsta diagnostic: 0 ani</paragraph>

</item><item>

<paragraph>Diagnostic principal: Antraxul</paragraph><paragraph>Vârsta diagnostic: 0 ani</paragraph>

</item><item>

<paragraph>Diagnostic de trimitere: Dermatofitoze</paragraph><paragraph>Vârsta diagnostic: 0 ani</paragraph>

</item><item>

<paragraph>Diagnostic de trimitere: Dermatofitoze</paragraph><paragraph>Vârsta diagnostic: 0 ani</paragraph>

</item><item>

<paragraph>Diagnostic principal: Botulismul</paragraph></item>

</list></text>

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Proceduri

Cardinalitate1..1

DescriereAceasta sectiune documenteaza procedurile ce au fost efectuate pe respectivul document clinic.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

component.section.code code codeSystemcodeSystemNamedisplayName

CE M: 1..1 codul sectiunii de Proceduri:<code codeSystemName="LOINC" code="29554-3" displayName="Procedure" codeSystem="2.16.840.1.113883.6.1" />

Component.section.title text M: 1..1 Titlul sectiuniiComponent.section.text text R: 1..1 Aici se introduc informatiile din sectiune puse intr-un format usor de

cititcomponent.section.entry.procedure

classCode="PROC"moodCode="EVN"/”INT”

R: 1..* cate un astfel de element pentru fiecare procedura codificata pe foaia de observatie;moodCode=EVN pentru procedurile efectuate si INT pentru procedurile de pe biletele de trimitere

component.section.entry.procedure.code

codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 tipul procedurii = codul ei

component.section.entry.procedure.text

text O: 0..1 Aici se introduc comentariile pentru procedura curenta

component .section.entry.procedure.statusCode

code="completed" CNE O: 0..1 se completeaza in CDA numai procedurile efectuate pacientului

component .section.entry.procedure.effectiveTime

dateStartdateEnd

IVL_TS

O: 0..1 Data de inceput si respectiv de sfarsit a efectuarii procedurii

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component .section.entry.procedure.priorityCode

CodeCodeSystemDisplayNameCodeSystemName

CE O: 0..1 Prioritatea procedurii

section.entry.procedure.targetSiteCode

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 Partea corpului unde este localizat diagnosticul

section.entry. procedure.targetSiteCode.qualifier.name

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care targetSite are si alte atribute (de exemplu “with laterality”) aici se salveaza numele atributului:<name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" />

section.entry. procedure.TargetSiteCode.qualifier.value

codecodeSystemcodeSystemNamedisplayName

CE O: 0..1 In cazul in care targetSite are si alte atribute (de exemplu “with laterality”) aici se salveaza valoarea atributului

section.entry. procedure.id

root II O:1..1 GUID poate fi folosit la relationarea documentelor

Exemplu

<component> <section> <code codeSystemName="LOINC" code="29554-3" displayName="Procedure" codeSystem="2.16.840.1.113883.6.1" /> <title>Proceduri</title> <text> <list> <item> <paragraph>Procedură: Consultatie medic primar - Cardiologie</paragraph> <paragraph>Vârstă: 24 ani</paragraph> </item> <item> <paragraph>Procedură: Interpretare analize - Cardiologie</paragraph> <paragraph>Vârstă: 24 ani</paragraph> </item> <item>

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<paragraph>Procedură: ECG ( electrocardiograma ) la Structura cardiovasculara.</paragraph> <paragraph>Vârstă: 24 ani</paragraph> </item> </list> </text> <entry> <procedure classCode="PROC" moodCode="EVN"> <code displayName="Consultatie medic primar - Cardiologie" code="C108" codeSystem="100.100.100.12" codeSystemName="ServiciiConsultatii"> <qualifier> <name displayName="Pachet servicii" codeSystemName="" code="" codeSystem="" /> <value displayName="BAZA | FACULTATIV | MINIMAL" code="" codeSystem="" codeSystemName=""/> </qualifier> </code> <statusCode code="completed" /> <effectiveTime> <low value="20080122094100.0000+02" /> <high value="20080124101034.0000+02" /> </effectiveTime> <priorityCode displayName="de urgenta" code="EM" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" /> </procedure> </entry> <entry> <procedure classCode="PROC" moodCode="EVN"> <code displayName=" Interpretare analize - Cardiologie " code=" C113" codeSystem="100.100.100.12" codeSystemName="ServiciiConsultatii"> <qualifier> <name displayName="Pachet servicii" codeSystemName="" code="" codeSystem="" /> <value displayName="BAZA | FACULTATIV | MINIMAL" code="" codeSystem="" codeSystemName=""/> </qualifier> </code> <statusCode code="completed" /> <effectiveTime> <low value="20080124104424.0000+02" /> <high value="20080124104424.0000+02" /> </effectiveTime> <priorityCode /> </procedure> </entry> <entry> <procedure classCode="PROC" moodCode="EVN"> <code displayName="ECG ( electrocardiograma )" code="1.21.28" codeSystem="100.100.100.4" codeSystemName="ProceduriDRG"> <qualifier> <name displayName="Pachet servicii" codeSystemName="" code="" codeSystem="" /> <value displayName="BAZA | FACULTATIV | MINIMAL" code="" codeSystem="" codeSystemName=""/> </qualifier> </code>

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<statusCode code="completed" /> <effectiveTime> <low value="20080124101050.0000+02" /> <high value="20080124102050.0000+02" /> </effectiveTime> <priorityCode /> <targetSiteCode displayName="Intregul compartiment al membrelor inferioare" code="276744008" codeSystem="2.16.840.1.113883.6.96” codeSystemName=”SNOMED CT”>" <qualifier> <name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Superficial" code="62372003" codeSystem="2.16.840.1.113883.6.96" /> </qualifier> </targetSiteCode> </procedure> </entry> </section></component>

Narativ<text><list>

<item><paragraph>Procedură: Proceduri cu distructie la nivelul sclerei la Cavum vergae Descriere locatie-sus.</paragraph><paragraph>Vârstă: 0 ani</paragraph>

</item><item>

<paragraph>Procedură: Alte proceduri excizionale asupra sclerei la Cavum vergae Descriere locatie-sus.</paragraph><paragraph>Vârstă: 0 ani</paragraph>

</item></list></text>

Page 61: Ghid Implementare CDA

Cerere proceduri imagistica

Descriere

Aceasta sectiune documenteaza procedura de imagistica dintr-o cerere de imagistica.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

component.section.code code codeSystemcodeSystemNamedisplayName

CE M: 1..1 codul sectiunii de Proceduri radiologice:<code codeSystemName="LOINC" code="18726-0" displayName=“Laboratory Imaging” codeSystem="2.16.840.1.113883.6.1" />

Component.section.title text M: 1..1 Titlul sectiuniiComponent.section.text text M: 1..1 Continutul sectiunii formatat pentru citire usoaracomponent.section.entry.procedure

classCode="PROC"moodCode="RQ0"/”INT”

R: 1..* cate un astfel de element pentru fiecare procedura codificata (moodCode=RQ0 pentru cererea imagistica, INT pentru procedurile de pe un bilet de trimitere)

component .section.entry.procedure.code

codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 tipul procedurii = codul ei

component .section.entry.procedure.statusCode

code="completed" CNE O: 0..1 se completeaza in CDA numai procedurile efectuate pacientului

component .section.entry.procedure.effectiveTime

value TS O: 0..1 Data procedurii

component .section.entry.procedure.priorityCode

displayNamecodecodeSystemcodeSystemName

CE O: 0..1 Prioritatea

component.section.entry displayName CE O: 0..1 Codul zonei corpului unde se face ecografia

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.procedure.targetSiteCode

codecodeSystemcodeSystemName

component .section.entry.procedure.targetSiteCode.qualifier.name

value CD O: 0..1 In cazul in care targetSiteCode are si alte atribute (de exemplu “with laterality”) atunci aici se salveaza date despre numele atributului:<name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" />

component .section.entry.procedure.TargetSiteCode.qualifier.value

value CD O: 0..1 In cazul in care targetSiteCode are si alte atribute (de exemplu “with laterality”) atunci aici se salveaza valoarea atributului

Component.section.entry.procedure.reference.externalDocument.id

root II O: 1..* Id-ul unul diagnostic asociat liniei curente de cerere de procedura, diagnostic ce se regaseste in sectiunea de diagnostice a documentului

Component.section.entry. procedure.id

root II O:1..1 GUID poate fi folosit la relationarea documentelor

Exemplu

<component> <section> <code codeSystemName="LOINC" code="18726-0" displayName=“Laboratory Imaging” codeSystem="2.16.840.1.113883.6.1" /> <title>Imagistica</title> <text> <list> <item> <paragraph>Test: ECO. SISTEM VASCULAR MEMBRE INFERIOARE - VENE</paragraph> </item> <item> <paragraph>Test: ECOGRAFIE CARDIACA + DOPPLER</paragraph> </item> </list> </text> <entry> <procedure classCode="PROC" moodCode="RQO">

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<code displayName="ECO. SISTEM VASCULAR MEMBRE INFERIOARE - VENE" code="1.22.15173" codeSystem="100.100.100.4" codeSystemName=”ProceduriDRG”/> <statusCode code="new" /> <effectiveTime value="20080124000000.0000+02" /> <priorityCode displayName="de rutina" code="R" codeSystem="2.16.840.1.113883.5.7" codeSystemName=”ActPriority”/> <targetSiteCode displayName="Intregul compartiment al membrelor inferioare" code="276744008" codeSystem="2.16.840.1.113883.6.96” codeSystemName=”SNOMED CT”> <qualifier> <name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Superficial" code="62372003" codeSystem="2.16.840.1.113883.6.96" codeSystemName=”SNOMED CT”/> </qualifier> </targetSiteCode> <reference> <externalDocument> <id root="6ef20425-c54d-40f2-b54b-7a31b6432201" /> </externalDocument> </reference> </procedure> </entry> <entry> <procedure classCode="PROC" moodCode="RQO"> <code displayName="ECOGRAFIE CARDIACA + DOPPLER" code="1.22.15181" codeSystem="100.100.100.4" codeSystemName=”ProceduriDRG”/> <statusCode code="new" /> <effectiveTime value="20080124000000.0000+02" /> <priorityCode displayName="de rutina" code="R" codeSystem="2.16.840.1.113883.5.7" codeSystemName=”ActPriority”/> <targetSiteCode displayName="Intreaga cavitate toracica stanga" code="184407001" codeSystem="2.16.840.1.113883.6.96" codeSystemName=”SNOMED CT”> <qualifier> <name displayName="with laterality" codeSystemName="SNOMED CT" code="78615007" codeSystem="2.16.840.1.113883.6.96" /> <value displayName="Superficial" code="26283006" codeSystem="2.16.840.1.113883.6.96" codeSystemName=”SNOMED CT”/> </qualifier> </targetSiteCode> <reference> <externalDocument> <id root="c7285379-1ca3-46ba-9fd0-bfcdac06b59f" /> </externalDocument> </reference> </procedure> </entry> </section></component>

Narativ<text> <list>

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<item> <paragraph>Test: ECO. SISTEM VASCULAR MEMBRE INFERIOARE - VENE</paragraph> </item> <item> <paragraph>Test: ECOGRAFIE CARDIACA + DOPPLER</paragraph> </item> </list></text>

Cerere laborator

Cardinalitate 0..*

Descriere

Aceasta sectiune contine diferite teste de laborator care sunt cerute pentru a fi efectuate asupra pacientului.

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

component.section.code code codeSystemcodeSystemNamedisplayName

CE M codul sectiunii de laborator:<code codeSystemName="LOINC" code="11502-2" displayName=“Laboratory Analysis“ codeSystem="2.16.840.1.113883.6.1" />

component.section.title TEXT M Titlul sectiuniicomponent.section.text TEXT M Campul care este folosit pentru a afisa datele acestei sectiuni intr-un

format usor de cititComponent.section.entry.procedure.text

TEXT O: 1..1 Aici se salveaza comentariile generale ale cererii de laborator

Component.section.com Code CE M: 1..* Cate o inregistrare pentru fiecare clasa de analize. Aici se salveaza

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ponent.section.code displayNamecodeSystemcodeSystemName

codul clasei de analize

Component.section.component.section.component

M: 1..* Cate o inregistrare pentru fiecare analiza de laborator ceruta

component.section.component.section.component.section.code

codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 Analiza de laborator ceruta

component .section.component.section.component.section.entry.procedure

moodCode M: 1..1 moodCode=RQO pentru cererile de analize, moodCode=INT pentru biletele de trimite la analize

component .section.component.section.component.section.entry.procedure.statusCode

code CE O: 0..1 starea liniei curente din cerere (new=nou ceruta, active=acceptata de laborator, nullified=stearsa, completed=efectuata)

component .section.component.section.component.section.entry.procedure.effectiveTime

value TS O: 0..1 Data cererii de analiza

Component.section.component.section.component.section.entry.procedure.priorityCode

CodeDisplayNameCodeSystemCodesystemName

CE O: 0..1 Prioritatea analizei curente

Component.section.component.section.component.section.reference.externalDocument.id

root II O: 0..1 Referinta catre diagnosticul asociat liniei curente din cererea de analiza. Referinta e catre un diagnostic din sectiunea de diagnostic a CDA-ului

Component.section.entry. procedure.id

root II O:1..1 GUID poate fi folosit la relationarea documentelor

Exemplu

<component>

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<section><code codeSystemName="LOINC" code="11502-2" displayName="Laboratory Analysis" codeSystem="2.16.840.1.113883.6.1" /><title>Laborator</title><text>

<content>Dată: 24.01.2008</content><table>

<tbody><tr>

<th>Clasă</th><th>Analiză</th><th>Prioritate</th>

</tr><tr>

<td rowspan="1">HEMATOLOGIE</td><td>VSH</td><td />

</tr><tr>

<td rowspan="2">COAGULARE( ELECTRA 1600C )</td><td>FIBRINOGEN</td><td />

</tr><tr>

<td>TIMP DE PROTROMBINA ( T. QUICK)</td><td />

</tr><tr>

<td rowspan="5">BIOCHIMIE - SANGE</td><td>ALBUMINA</td><td />

</tr><tr>

<td>COLESTEROL</td><td />

</tr><tr>

<td>GGT</td><td />

</tr><tr>

<td>GLUCOZA</td><td />

</tr><tr>

<td>TRIGLICERIDE</td><td />

</tr>

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<tr><td rowspan="1">SEROLOGIE</td><td>PROTEINA C REACTIVA (CRP)</td><td />

</tr></tbody>

</table></text><entry>

<procedure classCode="PROC" moodCode="RQO"><text>comentarii generale pentru cererea de analize</text><statusCode code="new" />

</procedure></entry>

<component><section>

<code displayName="HEMATOLOGIE" codeSystemName="AnaCod" code="0" codeSystem="100.100.100.7" /><component>

<section><code displayName="VSH" code="428" codeSystem="100.100.100.7" codeSystemName="AnaCod" /><entry>

<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode displayName="prioritate maxima" code="UR"

codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority"/><reference>

<externalDocument><id root="5474c742-10e1-4fdd-805b-dca602a9c15b" />

</externalDocument></reference>

</procedure></entry>

</section></component>

</section></component>

<component><section>

<code displayName="COAGULARE( ELECTRA 1600C )" codeSystemName="AnaCod" code="1" codeSystem="100.100.100.7" />

<component><section>

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<code displayName="FIBRINOGEN" code="326" codeSystem="100.100.100.7" codeSystemName="AnaCod" />

<entry><procedure classCode="PROC" moodCode="RQO">

<statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component><component>

<section><code displayName="TIMP DE PROTROMBINA ( T. QUICK)" code="327" codeSystem="100.100.100.7"

codeSystemName="AnaCod" /><entry>

<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component>

</section></component><component>

<section><code displayName="BIOCHIMIE - SANGE" codeSystemName="AnaCod" code="2" codeSystem="100.100.100.7" /><component>

<section><code displayName="ALBUMINA" code="338" codeSystem="100.100.100.7" codeSystemName="AnaCod"

/><entry>

<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component><component>

<section><code displayName="COLESTEROL" code="340" codeSystem="100.100.100.7"

codeSystemName="AnaCod" /><entry>

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<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component><component>

<section><code displayName="GGT" code="359" codeSystem="100.100.100.7" codeSystemName="AnaCod" /><entry>

<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component><component>

<section><code displayName="GLUCOZA" code="335" codeSystem="100.100.100.7"

codeSystemName="AnaCod" /><entry>

<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component><component>

<section><code displayName="TRIGLICERIDE" code="339" codeSystem="100.100.100.7"

codeSystemName="AnaCod" /><entry>

<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component>

</section>

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</component><component>

<section><code displayName="SEROLOGIE" codeSystemName="AnaCod" code="9" codeSystem="100.100.100.7" /><component>

<section><code displayName="PROTEINA C REACTIVA (CRP)" code="479" codeSystem="100.100.100.7"

codeSystemName="AnaCod" /><entry>

<procedure classCode="PROC" moodCode="RQO"><statusCode code="new" /><effectiveTime value="20080124000000.0000+02" /><priorityCode />

</procedure></entry>

</section></component>

</section></component>

</section></component>

Narativ<text>

<table><caption>Dată: 22.05.2009 Greutate: 78 Kg</caption><tbody>

<tr><th>Clasă</th><th>Analiză</th><th>Prioritate</th>

</tr><tr>

<td rowspan="5">HEMATOLOGIE</td><td>CONCENTRAT LEUCOCITAR</td><td />

</tr><tr>

<td>EX. PIC. GROASA SI FROTIU DE SANGE PT MALARIE</td><td />

</tr><tr>

<td>Examinare Morfologica - Frotiu sange venos</td><td />

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</tr><tr>

<td>HEMOLEUCOGRAMA COMPLETA</td><td />

</tr><tr>

<td>VSH</td><td />

</tr><tr>

<td rowspan="3">COAGULARE( ELECTRA 1600C )</td><td>INR</td><td />

</tr><tr>

<td>TIMP DE COAGULARE</td><td />

</tr><tr>

<td>TIMP DE PROTROMBINA ( T. QUICK)</td><td />

</tr><tr>

<td rowspan="5">BIOCHIMIE - SANGE</td><td>BILIRUBINA CONJUGATA (DIRECTA)</td><td />

</tr><tr>

<td>BILIRUBINA TOTALA</td><td />

</tr><tr>

<td>CALCIU IONIC SERIC</td><td />

</tr><tr>

<td>LIPIDE TOTALE</td><td />

</tr><tr>

<td>LITIU</td><td>prioritate maxima</td>

</tr></tbody>

</table></text>

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Rezultate laborator

Descriere

Aceasta sectiune contine rezultatele analizelor trimise de catre laborator.Referinta: http://wiki.ihe.net/index.php?title=PCC_TF-1/PHLAB

Page 73: Ghid Implementare CDA

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

component.section.code code codeSystemcodeSystemNamedisplayName

CE M Codul sectiunii:<code displayName="Laboratory Results" codeSystemName="LOINC" code="11502-2" codeSystem="2.16.840.1.113883.6.1" />

component.section.title TEXT M Titlul sectiuniicomponent.section.text TEXT M Campul care este folosit pentru a afisa datele acestei sectiuni intr-un

format usor de cititComponent.section.entry.procedure

CE M:1..1 Sectiune folosita pentru a introduce comentariile in momentul cererii de laborator. Rezultatul de laborator nu modifica nimic aici

Component.section.entry.procedure.text

TEXT M:1..1 Aici se introduc comentariile generale ale cererii

Component.section.component.section.code

codedisplayNamecodeSystemCodeSystemName

CE M:1..1 Clasa de analize

Component.section.component.section.component.section.code

CodedisplayNameCodeSystemCodeSystemName

CE M: 1..* Codul analizei cerute

Component.section.component.section.component.section.entry.procedure.text

TEXT O: 0..1 Comentariul analizei curente (introdus in momentul introducerii rezultatelor)

Component.section.component.section.component.section.entry.procedure.statusCode

code M: 1..1 Statusul analizei

Component.section.component.section.component.section.entry.procedure.effectiveTime

value TS M:1..1 Data in care s-a efectuat cererea pentru analiza curenta

Component.section.component.section.compone

CodeDisplayName

CE O: 0..1 Prioritatea analizei curente

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nt.section.entry.procedure.priorityCode

CodeSystemCodesystemName

Component.section.component.section.component.section.entry.procedure.entryRelationship

typeCode CE M:1..1 Cate o inregistrare pentru fiecare parametru al rezultatului pentru analiza curenta

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.code

displayNamecodecodeSystemcodeSystemName

CE M:1..1 Codul parametrului asociat analizei curente

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.statusCode

code CE M:1..1 Statusul parametrului analizei

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.effectiveTime

TS M:1..1 Data in care s-a dat rezultatul parametrului current al analizei curente

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.value

Xsi:typeUnitvalue

PQ M:1..1 Valoarea parametrului analizei

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.interpretationCode

CodeDisplayNamecodeSystemCodeSystemName

CE O:0..* Interpretarea rezultatului. Un rezultat poate avea mai multe interpretari (ex: Abnormal, Low, Significant Decrease).

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.referenceRange

Type=”ActRelationship”Typecode=”REFV”

M 1..1 Aici se specifica valorile normale pentru parametrul analizei

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Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.referenceRange.referenceObservationRange.value.low,high

Unitvalue

IVL_PQ

M 1..1 Valoarea minima si valoarea maxima considerate ca fiind normale

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship

typeCode=”COMP” O:0..*

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act

moodCode="EVN" classCode="ACT"

O:0..* Aici se pun informatii suplimentare pentru rezultatele analizelor (aparatul pe care s-a lucrat, comentarii de pe aparat, cine a lucrat, cine a validat)

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act.text.reference

Value O:0..1 Referinta catre narativul clasei unde se gaseste comentariul de pe aparatul pe care a fost lucrat rezultatul.

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act.participant

typeCode="DEV" O:0..1 Contine informatii cu privire la aparatul pe care s-a lucrat rezultatul.

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act.participant

typeCode="PRF" O:0..1 Contine informatii cu privire la persoana care a lucrat rezultatul.

Component.section.com typeCode="VRF" O:0..1 Contine informatii cu privire la persoana care a validat rezultatul.

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ponent.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act.participantComponent.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act.participant.participantRole.Id

ExtensionRoot

II M:1..1 Identificatorul participantului (analizorul pe care s-a lucrat, persoana care a lucrat, persoana care a validat).

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act.participant.participantRole.playingDevice. manufacturerModelName

TEXT M:1..1 Numele analizorului.

Component.section.component.section.component.section.entry.procedure.entryRelationship.observation.entryRelationship.act.participant.participantRole. playingEntity.Name

PN M:1..1 Numele persoanei.

Component.section.entry. procedure.id

root II O:1..1 GUID poate fi folosit la relationarea documentelor

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Exemplu

<component><section>

<code displayName="Laboratory Results" codeSystemName="LOINC" code="11502-2" codeSystem="2.16.840.1.113883.6.1" /><title>Rezultate laborator</title><text>

<paragraph><content>Data: 01.03.2008 15:26</content>

</paragraph><paragraph /><paragraph>

<content>Comentarii: </content><content />

</paragraph><paragraph />

</text><entry>

<procedure classCode="PROC" moodCode="RQO"><text /><statusCode code="new" />

</procedure></entry><component>

<section><code displayName="HEMATOLOGIE" codeSystemName="AnaCod" code="0" codeSystem="100.100.100.7" /><component>

<section><code displayName="HEMOLEUCOGRAMA COMPLETA" code="323" codeSystem="100.100.100.7"

codeSystemName="AnaCod" /><text /><entry>

<procedure classCode="PROC" moodCode="PRMS"><text>NIHON22: </text><statusCode code="active" /><effectiveTime value="20080301140754.7370+02" /><priorityCode /><entryRelationship typeCode="XCRPT">

<observation><code displayName="ERITROCITE" code="215"

codeSystem="100.100.100.7.1" codeSystemName=""/><statusCode code="active" /><effectiveTime value="20080301140754.6100+02" /><value xsi:type="PQ" unit="10³*10³/µL" value="4.52 " />

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<interpretationCode displayName="" code="N" codeSystem="2.16.840.1.113883.5.83" />

<referenceRange type="ActRelationship" typeCode="REFV"><referenceObservationRange>

<value xsi:type="IVL_PQ"><low unit="10³*10³/µL" value="3.7" /><high unit="10³*10³/µL"

value="5.1" /></value>

</referenceObservationRange></referenceRange>

</observation></entryRelationship><entryRelationship typeCode="XCRPT">

<observation><code displayName="HEMOGLOBINA" code="216"

codeSystem="100.100.100.7.1" /><statusCode code="active" /><effectiveTime value="20080301140754.6270+02" /><value xsi:type="PQ" unit="g/dl" value="12.1 " /><interpretationCode displayName="" code="N"

codeSystem="2.16.840.1.113883.5.83" /><referenceRange type="ActRelationship" typeCode="REFV">

<referenceObservationRange><value xsi:type="IVL_PQ">

<low unit="g/dl" value="12.0" /><high unit="g/dl" value="15.0" />

</value></referenceObservationRange>

</referenceRange></observation>

</entryRelationship><entryRelationship typeCode="XCRPT">

<observation><code displayName="HEMATOCRIT" code="217"

codeSystem="100.100.100.7.1" /><statusCode code="active" /><effectiveTime value="20080301140754.6400+02" /><value xsi:type="PQ" unit="%" value="42.2 " /><interpretationCode displayName="" code="N"

codeSystem="2.16.840.1.113883.5.83" /><referenceRange type="ActRelationship" typeCode="REFV">

<referenceObservationRange><value xsi:type="IVL_PQ">

<low unit="%" value="36.0" /><high unit="%" value="46.0" />

</value>

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</referenceObservationRange></referenceRange>

</observation></entryRelationship>

</procedure></entry>

</section></component>

</section></component>

</section></component>

Narativ<text>

<paragraph /><table>

<col width="300" align="left" valign="top" /><col width="100" align="left" valign="top" /><col width="100" align="left" valign="top" /><col width="100" align="left" valign="top" /><thead align="center" valign="top">

<tr><th scope="row" align="left" valign="top">Denumire</th><th scope="row" align="left" valign="top">Rezultat</th><th scope="row" align="left" valign="top">Unitate de masura</th><th scope="row" align="left" valign="top">Valori normale</th>

</tr><tr>

<th styleCode="Bold" scope="row" colspan="4" align="left" valign="top">APTT</th></tr>

</thead><tbody align="center" valign="top">

<tr align="left" valign="top"><td scope="row" align="left" valign="top">TIMP PARTIAL ACTIVAT DE TROMBOPLASTINA (APTT)</td><td styleCode="Bold" scope="row" align="left" valign="top">40.9</td><td scope="row" align="left" valign="top">sec</td><td scope="row" align="left" valign="top">25.0-40.0</td>

</tr></tbody>

</table></text>

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Bilet de trimitere primit

Descriere

Aceasta sectiune contine cateva detalii specifice biletului de trimitere primit. Referinta: http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1

Elemente si atributeElemente Atribute Tip R/M/O: Descriere

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data cardinalitateComponent.section.code Code

DisplayNameCodeSystemCodeSystemName

CE M 1..1 Cod in care se specifica tipul sectiunii: <code displayName="REASON FOR VISIT" codeSystemName="LOINC" code="29299-6" codeSystem="2.16.840.1.113883.6.1" />

Component.section.id Rootextension

II M: 1..1 Id-ul biletului de trimitere (seria si numarul)

Component.section.title text O: 0..1 Titlul sectiunii. Se completeaza numai daca este completat si narativul.Component.section.text M: 1..1 This contains a narrative description of the patient's reason for visit.Component.section.entry.observation.effectiveTime

value TS M: 1..1 Data biletului de trimitere

Exemplu

<component> <section xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns="urn:hl7-org:v3"> <templateId root="2.16.840.1.113883.10" extension="1.1.20" /> <id root="Nr-bilet-de-trimitere" extension="1 2" /> <code displayName="REASON FOR REFERRAL" codeSystemName="LOINC" code="29299-6" codeSystem="2.16.840.1.113883.6.1" /> <title>Bilet de trimitere primit</title> <text> <list> <caption>Unitatea trimiţătoare</caption> <item /> </list> <list> <caption>Medic trimiţător</caption> <item> <paragraph>Nume medic: MED AMB</paragraph> <paragraph>Parafă: 123456</paragraph> <paragraph>Contract: 1234</paragraph> <paragraph>Casa de asigurări: ASIGURARI</paragraph> </item> </list> </text>

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<entry> <observation classCode="OBS" moodCode="EVN"> <effectiveTime value="20110615000000.0000+03" /> </observation> </entry> </section> </component>

Narativ<text>

<list><caption>Detalii vizită</caption><item>

<paragraph>Serie şi număr: BT-40298</paragraph><paragraph>Data: 22.05.2009</paragraph><paragraph>PNS: </paragraph>

</item></list><list>

<caption>Unitate medicală</caption><item>

<paragraph>Denumire: </paragraph><paragraph>CUI: </paragraph><paragraph>Sediu: </paragraph><paragraph>Judeţul: </paragraph>

</item></list><list>

<caption>Medic trimiţător</caption><item>

<paragraph>Nume: POPESCU IRINA ELENA</paragraph><paragraph>Cod parafă: 866230</paragraph><paragraph>Număr contract: </paragraph><paragraph>Casa de asigurări: </paragraph><paragraph>Specialitate: </paragraph>

</item></list>

</text>

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Bilet de trimitere emis

Descriere

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Aceasta sectiune contine cateva detalii specifice biletului de trimitere emis.Referinta: http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.2

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

Component.section.code CodeDisplayNameCodeSystemCodeSystemName

CE M 1..1 Cod in care se specifica tipul sectiunii: <code displayName="REASON FOR REFERRAL" codeSystemName="LOINC" code="42349-1" codeSystem="2.16.840.1.113883.6.1" />

Component.section.id Rootextension

II M: 1..1 Id-ul biletului de trimitere (seria si numarul)

Component.section.title text O: 0..1 Titlul sectiunii. Se completeaza numai daca este completat si narativul.Component.section.text M: 1..1 The reason for referral section shall contain a narrative description of

the reason that the patient is being referred.Component.section.entry.observation

ClassCode=OBS O: 0..* observatie reprezentand un diagnostic de trimitere (referit din sectiunea evaluare)

Component.section.entry.observation.code

CodeDisplayNameCodeSystemCodeSystemName

CD M: 1..1 Tipul observatiei (diagnostic, in acest caz)

Component.section.entry observation.reference.externalDocument.id

Rootextension

II M:1..1 Referinta catre un diagnostic din sectiunea de diagnostice

Exemplu

<component> <section> <id root="Nr-bilet-de-trimitere" extension="BTIAA 9928272" /> <code displayName="REASON FOR REFERRAL" codeSystemName="LOINC" code="42349-1" codeSystem="2.16.840.1.113883.6.1" />

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<title>Observaţii de trimitere</title> <text> <list> <item> <paragraph>Diagnostic trimitere: INFECTIE URINARA</paragraph> </item> </list> </text> <entry> <observation classCode="OBS"> <code displayName="Diagnostic" codeSystemName="SNOMED CT" code="282291009" codeSystem="2.16.840.1.113883.6.96" /> <reference> <externalDocument> <id root="diagnoseID" extension="bd0292ed-7099-47ae-a85c-4deff3c424b5" /> </externalDocument> </reference> </observation> </entry> </section></component>

Narativ<text>

<list><caption>Detalii trimitere</caption><item>

<paragraph>Serie şi număr: BT-29986</paragraph><paragraph>Data: 22.05.2009</paragraph><paragraph>PNS: </paragraph><paragraph>Categorie asigurat: Salariati</paragraph><paragraph>Pachet servicii medicale: PACHET DE BAZA</paragraph>

</item></list><list>

<caption>Unitatea trimiţătoare</caption><item>

<paragraph>Denumire: ORG</paragraph><paragraph>CUI: </paragraph><paragraph>Sediu: </paragraph><paragraph>Judeţul: </paragraph>

</item></list><list>

<caption>Medic trimiţător</caption><item>

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<paragraph>Nume: MEDIC ION</paragraph><paragraph>Cod parafă: 322134</paragraph><paragraph>Număr contract: C7789</paragraph><paragraph>Casa de asigurări: CNAS</paragraph><paragraph>Specialitate: Chirurgie generala</paragraph>

</item></list><list>

<caption>Unitatea de primire</caption><item>

<paragraph>Denumire: </paragraph><paragraph>CUI: </paragraph><paragraph>Sediu: </paragraph><paragraph>Judeţul: </paragraph>

</item></list><list>

<caption>Medic de primire</caption><item>

<paragraph>Nume: </paragraph><paragraph>Cod parafă: </paragraph><paragraph>Specialitate: Laborator farmaceutic</paragraph>

</item></list>

</text>

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Alergii

DescriereAceasta sectiune contine lista de alergii.http://www.hl7.org/v3ballot2007sep/html/infrastructure/cda/SampleCDADocument.xmlhttp://www.jamia.org/cgi/reprint/M1888v1.pdfhttp://xml.coverpages.org/CDA-ReleaseTwoSample200403.xml

Elemente si atribute

Elemente Atribute Tip data

R/M/O:cardinalitate Descriere

section.code code codeSystemcodeSystemNamedisplayName

CE M: 1..1 codul sectiunii de Alergii : <code codeSystemName="LOINC" code="10155-0" codeSystem="2.16.840.1.113883.6.1" />

Section.title   text M: 1..1 Titlul sectiuniiSection.text   text R:1..1 Aici se introduc informatiile din sectiune puse intr-un format

usor de cititsection.entry.observation classCode   R: 1..* cate un astfel de element pentru fiecare diagnostic codificatsection.entry.observation.code

code codeSystemcodeSystemNamedisplayName

CE M: 1..1 Observatie = Manifestarea alergiei (ex: Pruritis, Hives, Itching etc ) .

section.entry.observation.entryRelationship

typeCode=”MFST”

M: 1..1 Used to say that the source is a manifestation of the target (for instance, source "hives" is a manifestation of target "penicillin allergy").

section.entry.observation.entryRelationship.observation.code

code codeSystemcodeSystemName

CE M: 1..1 Tipul alergiei. Poate fi specific (“Penicillin allergy”, “Cat allergy” etc) sau general ("Adverse reaction to drug", “Allergy”, “Food allergy”). In al doilea caz se completeaza si un qualifier in care se precizeaza cauza

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displayName alergiei.section.entry.observation.entryRelationship.observation.code.qualifier

namevalue

CR O:0..3 Certitudinea alergiei (optional):<name displayName="Certainity of diagnosis" codeSystemName="SNOMED CT" code="106230009" codeSystem="2.16.840.1.113883.6.96" />Severitatea alergiei (optional) :<name displayName="Has severity" codeSystemName="SNOMED CT" code="43749003" codeSystem="2.16.840.1.113883.6.96" />Substanta / elementul care cauzeaza alergia:<name code="246075003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="causative agent"/>

section.entry.observation.effectiveTime

value IVL_TS

R:1..1 Data identificare

section.entry.observation.entryRelationship.observation.entryRelationship.observation.text

text ED R:1..1 Data diagnosticare

section.entry..observation.entryRelationship.observation.entryRelationship.observation.text

text ED R:1..1 Data rezolvare pentru section.entry.observation.entryRelationship.observation.entryRelationship.observation.code: code = '413947000' & codeSystem='2.16.840.1.113883.6.96'

Section.entry.observation.text

text ED O: 0..1 Observatii asociate alergiei curente

section.entry.observation.id root II O:1..1 GUID poate fi folosit la relationarea documentelor

Exemplu

<section><code codeSystemName="LOINC" code="10155-0" codeSystem="2.16.840.1.113883.6.1" /><title>Allergies &amp; Adverse Reactions</title><text>

<list><item>

<content styleCode="Bold">Diagnostic probabil: Adverse reaction to drug – codeine . </content><content>Manifestare: Pruritis, Moderat</content>

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</item></list>

</text><entry>

<observation><code code="32738000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Pruritis"/><text>observatie</text><effectiveTime value="20080719000000.0000+03" /><entryRelationship typeCode="MFST">

<observation><code displayName="Adverse reaction to drug" code="62014003" codeSystem="2.16.840.1.113883.6.96">

<qualifier><name code="246075003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED

CT" displayName="causative agent"/><value code="1476002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED

CT" displayName="codeine"/></qualifier><qualifier>

<name displayName="Has severity" codeSystemName="SNOMED CT" code="43749003" codeSystem="2.16.840.1.113883.6.96" />

<value displayName="Moderat" code="6736007" codeSystem="2.16.840.1.113883.6.96" /></qualifier><qualifier>

<name displayName="Certainity of diagnosis" codeSystemName="SNOMED CT" code="106230009" codeSystem="2.16.840.1.113883.6.96" />

<value displayName="Diagnostic probabil" code="2931005" codeSystem="2.16.840.1.113883.6.96" />

</qualifier></code><statusCode code="completed" /><entryRelationship typeCode="MFST">

<observation><code displayName="Onset date" codeSystemName="SNOMED CT" code="298059007"

codeSystem="2.16.840.1.113883.6.96" /><text>20080718000000.0000+03</text>

</observation></entryRelationship><entryRelationship typeCode="MFST">

<observation><code displayName="Resolution date" codeSystemName="SNOMED CT" code="413947000"

codeSystem="2.16.840.1.113883.6.96" /><text>20080720000000.0000+03</text>

</observation></entryRelationship>

</observation></entryRelationship>

</observation>

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</entry></section>

Narativ<text>

<list><item>

<content styleCode="Bold">Medie</content><content>alergie la </content><content styleCode="Bold">alergen - venin de viespe</content><content>, manifestată prin </content><content styleCode="Bold">rinita alergica si vazomotorie</content><content>.</content>

</item></list>

</text>

Antecedente familiale

DescriereAceasta sectiune contine lista de antecedente familiale.http://www.hl7.org/v3ballot2007sep/html/infrastructure/cda/SampleCDADocument.xml

Elemente si atributeElemente Atribute Tip data R/M/O:

cardinalitateDescriere

section.code code CE M: 1..1 Codul sectiunii de Family History:<code codeSystemName="LOINC" code="10157-2" codeSystem="2.16.840.1.113883.6.1" />

codeSystemcodeSystemName

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displayNameSection.title   text M: 1..1 Titlul sectiuniiSection.text   text R:1..1 Aici se introduc informatiile din sectiune puse intr-un

format usor de cititsection.entry.observation classCode="OBS"

moodCode="EVN"  R: 1..* cate un astfel de element pentru fiecare antecedent

section.entry.observation.negationInd

Boolean O: 0..1 =true – indica faptul ca nu are antecedentul specificat=false - default

section.entry.observation.code

code CE M: 1..1 tipul antecedenteul medical (diagnosticul)codeSystemcodeSystemNamedisplayName

section.entry.observation.code.qualifier.name

code CE O: 0..1 In cazul in care tipul diagnosticului are si alte atribute (de exemplu “has severity”) aici se salveaza numele atributului:<name displayName="Has severity" codeSystemName="SNOMED CT" code="43749003" codeSystem="2.16.840.1.113883.6.96" />

codeSystemcodeSystemNamedisplayName

section.entry.observation.code.qualifier.value

code CE O: 0..1 In cazul in care tipul diagnosticului are si alte atribute (de exemplu “has severity”) aici se salveaza valoarea atributului

codeSystemcodeSystemNamedisplayName

Section.entry.observation.text   TEXT O: 0..1 Observatii asociate antecedentului curentSection.entry.observation.effectiveTime

value TS O: 1..1 Data in care a fost diagnosticat antecedentul medical

Section.entry.observation.subject     M: 1..1

Element ce identifica relatia dintre pacient si un membru al familiei.

Section.entry.observation.subject.relatedSubject     M: 1..1

Va contine tipul de relatia intre pacient si membrul familiei

Section.entry.observation.subject.relatedSubject.code

code CE M: 1..1 Tipul de relatie existenta intre pacient si membrul familieicodeSystem

codeSystemNamedisplayName

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Section.entry.observation.entryRelationship

typeCode   R:0..1 Daca membrul famililie a decedat din cauza conditiei medicale adaugate, acest lucru se va specifica in acest element, setand typeCode="CAUS"

Section.entry.observation.entryRelationship.observation.code

codecodeSystemcodeSystemNamedisplayName

CE R: 0..1 Decesul membrului de familie codificat

Section.entry.observation.entryRelationship.observation.effectiveTime

  TS R:0..1 Data la care a survenit decesul

Exemplu<section>

<code codeSystemName="LOINC" code="10157-2" codeSystem="2.16.840.1.113883.6.1" /><title>Family History</title><text>

<list><item>No burns and corrosions</item><item>Bunic a avut certain early complications of trauma. A cauzat deces în anul 1999.</item><item>Copil a avut cleft lip and cleft palate.</item>

</list></text><entry>

<observation classCode="OBS" moodCode="EVN" negationInd="true"><code displayName="Burns and corrosions" code="T20-T32.9" codeSystem="2.16.840.1.113883.6.3" /><statusCode code="completed" /><effectiveTime /><subject contextControlCode="AN">

<relatedSubject><code />

</relatedSubject></subject>

</observation></entry><entry>

<observation classCode="OBS" moodCode="EVN"><code displayName="Certain early complications of trauma" code="T79-T79.9" codeSystem="2.16.840.1.113883.6.3">

<qualifier><name displayName="Has severity" codeSystemName="SNOMED CT" code="43749003"

codeSystem="2.16.840.1.113883.6.96" />

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<value displayName="Medie" code="255604002" codeSystem="2.16.840.1.113883.6.96" /></qualifier>

</code><statusCode code="completed" /><effectiveTime value="20080703000000.0000+03" /><subject contextControlCode="AN">

<relatedSubject><code displayName="Bunic" code="GRFTH" codeSystem="2.16.840.1.113883.5.111" />

</relatedSubject></subject><entryRelationship typeCode="CAUS">

<observation classCode="OBS" moodCode="EVN"><code displayName="death" codeSystemName="SNOMED CT" code="399347008"

codeSystem="2.16.840.1.113883.6.96" /><statusCode code="completed" /><effectiveTime value="1999" />

</observation></entryRelationship>

</observation></entry><entry>

<observation classCode="OBS" moodCode="EVN"><code displayName="Cleft lip and cleft palate" code="Q35-Q37.9" codeSystem="2.16.840.1.113883.6.3">

<qualifier><name displayName="Has severity" codeSystemName="SNOMED CT" code="43749003"

codeSystem="2.16.840.1.113883.6.96" /><value displayName="Severa" code="24484000" codeSystem="2.16.840.1.113883.6.96" />

</qualifier></code><text>adsadasd</text><statusCode code="completed" /><effectiveTime value="20080703000000.0000+03" /><subject contextControlCode="AN">

<relatedSubject><code displayName="Copil" code="CHILD" codeSystem="2.16.840.1.113883.5.111" />

</relatedSubject></subject>

</observation></entry>

</section>

Narativ<text>

<list><item>Bunic a avut tulburari de somn neorganice. A cauzat deces în anul 1965.</item>

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</list></text>

Imunizari

DescriereAceasta sectiune contine lista de imunizari/vitaminizari. Vezi http://wiki.ihe.net/index.php?title=Immunizations

Elemente si atributeElemente Atribute Tip data R/M/

O:cardinalitateDescriere

Component.section.code code CE M: 1..1 Codul care identifica sectiunea de imunizari (code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/)

codeSystemcodeSystemNamedisplayName

component.section.title   TEXT M: 1..1 Titlul sectiuniicomponent.section.text   TEXT M: 1..1 Campul care este folosit pentru a afisa datele introduse intr-o forma

usor citibilaComponent.section.entry.substanceAdministration

typeCode   M:1..1  O linie din imunizari; typeCode are valoarea SBADM; moodCode are valoarea EVN; daca s-a facut imunizarea atunci negationInd va fi false, iar daca imunizarea nu s-a efectuat din diverse motive negationInd va fi true, urmand ca in observatii sa se treaca motivul.

moodCodenegationInd

Component.section.entry.substanceAdministration.code

code CE M: 1..1 Semnifica faptul ca actul este o imunizare;<code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/>

codeSystemcodeSystemName

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displayNameComponent.section.entry.substanceAdministration.repeatNumber

lowIVL_INT O:0..1 Tip imunizare: 0=vaccinare; 1=revaccinare

component.section.entry.substanceAdministration.text

  TEXT O:0..1 Comentarii asociate liniei curente din imunizari

component.section.entry.substanceAdministration.effectiveTime

value TS O:0..1 Data imunizarii.

component.section.entry.substanceAdministration.approachSiteCode

code CE O:0..1 Partea corpului pe unde se va administra medicamentulValueSet: SubstanceAdministrationSitecodeSystem

codeSystemNamedisplayName

component.section.entry.substanceAdministration.routeCode

code CE O:0..1 Ruta de administrare a medicamentuluiValueSet: SubstanceAdministrationRoutecodeSystem

codeSystemNamedisplayName

component.section.entry.substanceAdministration.doseQuantity

value PQ O:0..1 Dozaunit

component.section.entry.substanceAdministration.consumable.manufacturedProduct.manufacturedLabeledDrug.code

code CE O:0..1 Codul imunizarii administrate ValueSet: 3.3.3.3.9.1 - Hm3MedicalServiceImmunization

codeSystemcodeSystemNamedisplayName

component.section.entry substanceAdministration.entryRelationship

typeCode   O:0..1 typecode va fi "SUBJ" in cazul unui entry pentru numarul medicamentului prescris, si va fi setat pe 'CAUS' in cazul in care imunizarea nu a avut loc si se face referire catre o alergie

inversionInd    O:0..1 va fi setat pe true in caz ca entry-ul se refera la o alergiecomponent.section.entry substanceAdministration.entryRelationship.observation.id

Root II O:0..1 Referinta catre o alergie din sectiunea de alergii in cazul in care nu s-a putut face imunizareaValueSet: AllergyCause

extension

component.section.entry code CE O:0..1 Codul ce indica numarul medicamentului prescris

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substanceAdministration.entryRelationship.observation.code

<code code='30973-2' displayName='Dose Number' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

codeSystemcodeSystemNamedisplayName

component.section.entry substanceAdministration.entryRelationship.observation.value

value INT  O:0..1 Indica numarul dozei de imunizare din seria de imunizari descrisa in documentul curent

Component.section.entry. substanceAdministration.id

root II O:1..1 GUID poate fi folosit la relationarea documentelor

Exemplu

<section><code code='11369-6' displayName='HISTORY OF IMMUNIZATIONS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/><text>

Text</text><entry>

<substanceAdministration typeCode='SBADM' moodCode='EVN' negationInd='true | false'><code code='IMMUNIZ' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode'/><text>

''<text><statusCode code='completed'/><effectiveTime value=''/><repeatNumber value='0'/><!-- The reasonCode would normally provide a reason why the immunization was

not performed. It isn't supported by CDA R2, and so comments will have to suffice. <reasonCode code='' codeSystem='' codeSystemName='ActNoImmunizationReasonIndicator'/> -->

<routeCode code='' codeSystem='' codeSystemName='RouteOfAdministration'/><approachSiteCode code='' codeSystem='' codeSystemName='HumanSubstanceAdministrationSite'/><doseQuantity value='' units=''/><consumable typeCode='CSM'>

<manufacturedProduct classCode='MANU'><manufacturedLabeledDrug classCode='MMAT' determinerCode='KIND'>

<code code='' codeSystem='' codeSystemName=''/></manufacturedLabeledDrug>

</manufacturedProduct></consumable>

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<!-- An optional entry relationship that identifies the immunization series number --><entryRelationship typeCode='SUBJ'>

<observation typeCode='OBS' moodCode='EVN'><code code='30973-2' displayName='Dose Number' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/><statusCode code='completed'/><value xsi:type='INT' value=''/>

</observation></entryRelationship>

<entryRelationship inversionInd='true' typeCode='CAUS'><observation typeCode='OBS' moodCode='EVN'>

<id root='' extension=''/></observation>

</entryRelationship>

</substanceAdministration></entry>

</section>

Narativ

<text><content>Data efectuarii imunizarilor:</content><table>

<tbody><tr>

<th>Felul</th><th>P.CG</th><th>A.V.</th><th>P.P.</th><th>DiTe</th><th>DiTePer</th><th>A.T.</th><th>ATPA</th><th>TAB</th><th>Antirujeolic</th><th>Antifoidic</th><th>Antigripal</th>

</tr><tr>

<td rowspan="3">Vaccinari</td><td align="center"></td><td align="center"></td>

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<td align="center">01.01.2008</td><td align="center"></td><td align="center"></td><td align="center">15.01.2008</td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td>

</tr><tr>

<td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td>

</tr><tr>

<td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td>

</tr><tr>

<td rowspan="3">Revaccinari</td><td align="center"></td><td align="center"></td><td align="center">01.02.2008</td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td>

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<td align="center"></td><td align="center"></td>

</tr><tr>

<td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td>

</tr>

<td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td></tr>

</tbody></table>

</text>

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Riscuri

DescriereAceasta sectiune contine o descriere a riscurilor la care pacientul se expune in urma unei proceduri, anestezie planificata, etc.. Vezi http://wiki.ihe.net/index.php?title=Pre-procedure_Risk_Assessment

Elemente si atributeElemente Atribute Tip data R/M/O:cardinalitate Descrierecomponent.section.code code CE M: 1..1 codul sectiunii de Riscuri:

<code code='11450-4' displayName='PROBLEM LIST' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

codeSystemcodeSystemNamedisplayName

Component.section.title   text M: 1..1 Titlul sectiuniiComponent.section.text   text R: 1..1 Aici se introduc informatiile din sectiune puse intr-un format

usor de cititsection.entry.observation classCode

moodCode  R: 1..* classCode='OBS' - riscul reprezinta o observatie; moodCode

= 'EVN'-este un faptnegationInd   O:0..1 Ia valoarea 'true' atunci cand se doreste semnalarea faptului

ca nu are loc riscul respectivsection.entry.observation.code code CE M: 1..1 Indica procesul de stabilire a riscului: (64572001) Condition,

(139174000) Symptom, (404684003) Finding , (409586006) Complaint , (248536006) Functional limitation, (55607006) Problem , (282291009) Diagnosis; Vocabular: SNOMEDValueSet: Hm3MethodFinding

codeSystemcodeSystemNamedisplayName

section.entry.observation.effectiveTime

dateStart IVL_TS O:0..1 Intervalul de timp in care observatia este valabiladateEnd      

section.entry.observation.value

code CD O:0..1 Probleme, plângeri, simptome, constatări, diagnostice sau limitări funcţionaleValueSet: Hm3Risk

codeSystem    codeSystemName    displayName    

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section.entry.observation.text TEXT O: 0..1 Comentarii

Exemplu<section>

<code code='11450-4' displayName='PROBLEM LIST' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/><title>Riscuri</title><text>

Text</text><entry>

<observation classCode='OBS' moodCode='EVN' negationInd=' false | true '><code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/><statusCode code='completed'/><effectiveTime>

<low value=' '/><high value=' '/>

</effectiveTime><value xsi:type='CD' code=' ' codeSystem=' ' displayName=' ' codeSystemName=' '></value>

</observation></entry>

</section>

Narativ<text>

<list><item>

<paragraph>Posibila infectie a urechii</paragraph><paragraph>Procesul de stabilire: diagnostic</paragraph><paragraph>Perioada: 01.01.2008 - 01.02.2008</paragraph>

</item></list>

</text>

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Semne vitale copil

DescriereAceasta sectiune documenteaza – daca este cazul – greutatea, inaltimea si alte semne vitale ale copilului (contine aceleeasi campuri ale sectiunii semene vitale, in plus fiind P.C – perimetru cranian si P.T. – perimetru toracic).

Elemente si atributeElemente Atribute Tip data R/M/O: cardinalitate Descriere

Component.section.codecode codeSystemcodeSystemNamedisplayName

CE M: 1..1 codul sectiunii: <code codeSystemName="LOINC" code="8716-3" codeSystem="2.16.840.1.113883.6.1" displayName=”VitalSigns”/>

component.section.title TEXT Titlul sectiunii component.section.text TEXT Campul care este folosit pentru a afisa detaliile

acestei sectiuni in format text, pentru vizualizari section.entry.observation classCode

moodCodeR: 1..* cate un astfel de element pentru fiecare semn vital

section.entry.observation.code

CodeDisplayNamecodeSystemcodeSystemName

CE M: 1..1 tipul semnului vital

section.entry.observation.value

xsi:typeunitvaluecode

PQ,RTO_PQ_PQ

CD

M: 1..1 Tipul de data pentru valoare si valoarea semnului vital

component.section.entry.observation.effectiveTime

value TS O: 0..1 Data in care s-au executat masuratorile

Exemplu<component>

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<section> <code codeSystemName="LOINC" code="8716-3" codeSystem="2.16.840.1.113883.6.1" displayName=”VitalSigns”/> <title>Semne Vitale</title> <text> <table> <tbody> <tr> <th>Dată / Oră</th> <th>22.01.2008 09:15:00</th> <th>24.01.2008 10:16:52</th> </tr> <tr> <th>Înălţime</th> <td align="center">165 Cm</td> <td align="center">165 Cm</td> </tr> <tr> <th>Greutate</th> <td align="center">61 Kg</td> <td align="center">60 Kg</td> </tr> <tr> <th>IMC</th> <td align="center">22,41 Kg/Cm2</td> <td align="center">22,04 Kg/Cm2</td> </tr> <tr> <th>ISC</th> <td align="center">0,17 Cm2</td> <td align="center">0,17 Cm2</td> </tr> <tr> <th>Temperatură</th> <td align="center">37,4 Grade C</td> <td align="center">37 Grade C</td> </tr> <tr> <th>Puls</th> <td align="center">85 / min</td> <td align="center">82 / min</td> </tr> <tr> <th>Ritm cardiac</th> <td align="center">Tahicardie</td> <td align="center">Puls neregulat</td> </tr> <tr>

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<th>Respiraţie</th> <td align="center">23 / min</td> <td align="center">21 / min</td> </tr> <tr> <th>Sistolică</th> <td align="center">160 mm[Hg]</td> <td align="center">148 mm[Hg]</td> </tr> <tr> <th>Diastolică</th> <td align="center">90 mm[Hg]</td> <td align="center">80 mm[Hg]</td> </tr> <tr> <th>Poziţie manşeta</th> <td align="center">Bratul drept</td> <td align="center">Bratul drept</td> </tr>

<tr> <th>Perimetru cranian</th> <td align="center">60 cm2</td> <td align="center">80 cm2</td> </tr>

<tr> <th>Perimetru toracic</th> <td align="center">100 cm2</td> <td align="center">110 cm2</td> </tr> </tbody> </table> </text> <entry> <observation> <code displayName="Body height measure" codeSystemName="SNOMED CT" code="50373000" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="cm" value="165" /> </observation> </entry> <entry> <observation> <code displayName="Body weight measure" codeSystemName="SNOMED CT" code="363808001" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="kg" value="61" /> </observation>

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</entry> <entry> <observation> <code displayName="Body mass index" codeSystemName="SNOMED CT" code="60621009" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="22,41" /> <denominator value="1" /> </value> </observation> </entry> <entry> <observation> <code displayName="Body surface area" codeSystemName="SNOMED CT" code="301898006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" value="0,17" /> </observation> </entry> <entry> <observation> <code displayName="Body temperature" codeSystemName="SNOMED CT" code="386725007" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="grade C" value="37,4" /> </observation> </entry> <entry> <observation> <code displayName="Heart rate" codeSystemName="SNOMED CT" code="364075005" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="85" /> <denominator unit="min" value="1" /> </value> </observation> </entry> <entry> <observation> <code displayName="Respiratory rate" codeSystemName="SNOMED CT" code="86290005" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="23" /> <denominator unit="min" value="1" />

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</value> </observation> </entry> <entry> <observation> <code displayName="Regularity of heart rhythm" codeSystemName="SNOMED CT" code="364074009" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="CD" displayName="Tahicardie" code="3424008" codeSystem="2.16.840.1.113883.6.96" /> </observation> </entry> <entry> <observation> <code displayName="Cuff blood pressure" codeSystemName="SNOMED CT" code="251076008" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <targetSiteCode displayName="Bratul drept" code="368209003" codeSystem="2.16.840.1.113883.6.96" /> <entryRelationship typeCode="COMP"> <observation> <code displayName="Systolic BP" codeSystemName="SNOMED CT" code="271649006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="mm[Hg]" value="160" /> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation> <code displayName="Diastolic BP" codeSystemName="SNOMED CT" code="271650006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="mm[Hg]" value="90" /> </observation> </entryRelationship> </observation> </entry> <entry> <observation> <code displayName="CerebralPerimeter" codeSystemName="SNOMED CT" code="10927008" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="cm" value="60" /> </observation> </entry> <entry> <observation> <code displayName="ThoracicPerimeter" codeSystemName="SNOMED CT" code="140097005" codeSystem="2.16.840.1.113883.6.96" />

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<statusCode code="completed" /> <effectiveTime value="20080122091500.0000+02" /> <value xsi:type="PQ" unit="cm" value="100" /> </observation> </entry> <entry> <observation> <code displayName="Body height measure" codeSystemName="SNOMED CT" code="50373000" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" unit="258672001" value="165" /> </observation> </entry> <entry> <observation> <code displayName="Body weight measure" codeSystemName="SNOMED CT" code="363808001" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" unit="258683005" value="60" /> </observation> </entry> <entry> <observation> <code displayName="Body mass index" codeSystemName="SNOMED CT" code="60621009" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="22,04" /> <denominator value="1" /> </value> </observation> </entry> <entry> <observation> <code displayName="Body surface area" codeSystemName="SNOMED CT" code="301898006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" value="0,17" /> </observation> </entry> <entry> <observation> <code displayName="Body temperature" codeSystemName="SNOMED CT" code="386725007" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" unit="258710007" value="37" /> </observation>

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</entry> <entry> <observation> <code displayName="Heart rate" codeSystemName="SNOMED CT" code="364075005" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="82" /> <denominator unit="min" value="1" /> </value> </observation> </entry> <entry> <observation> <code displayName="Respiratory rate" codeSystemName="SNOMED CT" code="86290005" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="RTO_PQ_PQ"> <numerator value="21" /> <denominator unit="min" value="1" /> </value> </observation> </entry> <entry> <observation> <code displayName="Regularity of heart rhythm" codeSystemName="SNOMED CT" code="364074009" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="CD" displayName="Puls neregulat" code="361138002" codeSystem="2.16.840.1.113883.6.96" /> </observation> </entry> <entry> <observation> <code displayName="Cuff blood pressure" codeSystemName="SNOMED CT" code="251076008" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <targetSiteCode displayName="Bratul drept" code="368209003" codeSystem="2.16.840.1.113883.6.96" /> <entryRelationship typeCode="COMP"> <observation> <code displayName="Systolic BP" codeSystemName="SNOMED CT" code="271649006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" unit="mm[Hg]" value="148" /> </observation> </entryRelationship> <entryRelationship typeCode="COMP">

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<observation> <code displayName="Diastolic BP" codeSystemName="SNOMED CT" code="271650006" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" unit="mm[Hg]" value="80" /> </observation> </entryRelationship> </observation> </entry> <entry> <observation> <code displayName="CerebralPerimeter" codeSystemName="SNOMED CT" code="10927008" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" unit="cm" value="80" /> </observation> </entry> <entry> <observation> <code displayName="ThoracicPerimeter" codeSystemName="SNOMED CT" code="140097005" codeSystem="2.16.840.1.113883.6.96" /> <statusCode code="completed" /> <effectiveTime value="20080124101652.0000+02" /> <value xsi:type="PQ" unit="cm" value="110" /> </observation> </entry> </section></component>

Narativ<text>

<table><tbody>

<tr><th>Dată / Oră</th><th>22.01.2008 09:15:00</th><th>24.01.2008 10:16:52</th>

</tr><tr>

<th>Înălţime</th><td align="center">165 Cm</td><td align="center">165 Cm</td>

</tr><tr>

<th>Greutate</th><td align="center">61 Kg</td>

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<td align="center">60 Kg</td></tr><tr>

<th>IMC</th><td align="center">22,41 Kg/Cm2</td><td align="center">22,04 Kg/Cm2</td>

</tr><tr>

<th>ISC</th><td align="center">0,17 Cm2</td><td align="center">0,17 Cm2</td>

</tr><tr>

<th>Temperatură</th><td align="center">37,4 Grade C</td><td align="center">37 Grade C</td>

</tr><tr>

<th>Puls</th><td align="center">85 / min</td><td align="center">82 / min</td>

</tr><tr>

<th>Ritm cardiac</th><td align="center">Tahicardie</td><td align="center">Puls neregulat</td>

</tr><tr>

<th>Respiraţie</th><td align="center">23 / min</td><td align="center">21 / min</td>

</tr><tr>

<th>Sistolică</th><td align="center">160 mm[Hg]</td><td align="center">148 mm[Hg]</td>

</tr><tr>

<th>Diastolică</th><td align="center">90 mm[Hg]</td><td align="center">80 mm[Hg]</td>

</tr><tr>

<th>Poziţie manşeta</th><td align="center">Bratul drept</td><td align="center">Bratul drept</td>

</tr>

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<tr><th>P.C.</th><td align="center">90 cm2</td><td align="center">90 cm2</td>

</tr><tr>

<th>P.T.</th><td align="center">120 cm2</td><td align="center">120 cm2</td>

</tr></tbody>

</table></text>

Estimare data nastere

DescriereAceasta sectiune contine o estimare a datei nasterii copilului, precum si metodele de determinare a acesteia. Vezi http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.1

Elemente si atributeElemente Atribute Tip R/M/O:cardinalitate Descriere

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dataComponent.section.code code CE M: 1..1 codul sectiunii:

<code code='70000-1' displayName='ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

codeSystemcodeSystemNamedisplayName

component.section.title   TEXT   Titlul sectiuniicomponent.section.text   TEXT   Campul care este folosit pentru a afisa detaliile acestei

sectiuni in format text, pentru vizualizarisection.entry.observation.code Code CD M: 1..1 <code code='11778-8'

codeSystem='2.16.840.1.113883.6.1'/> indica faptul ca data nasterii este estimata clinic

DisplayNamecodeSystemcodeSystemName

section.entry.observation.value xsi:type TS M: 1..1 Data estimatavalue  

section.entry.observation.entryRelationship.observation.code

code CD M: 1..* metoda de stabilire a datei nasteriicodeSystem     ValueSet: HM3DueDateEstimatedcodeSystemName    displayName      

component.section.entry.observation.text

  text O: 0..1 Comentarii

Exemplu

<section><code code='70000-1' displayName='ESTIMATED DELIVERY DATE-^PATIENT-FIND-PT-NAR-' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/><title>Estimare data nastere</title><text>

Text</text><entry>

<observation classCode='OBS' moodCode='EVN'><statusCode code='completed'/><code code='11778-8'

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displayName='DELIVERY DATE-TMSTP-PT-^PATIENT-QN-CLINICAL.ESTIMATED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/><text>''</text><value xsi:type='TS' value=' '/><entryRelationship typeCode='SPRT'>

<observation classCode='OBS' moodCode='EVN'><statusCode code='completed'/><code code='[11779-6|70000-4|11781-2|70000-5|70000-6]'

codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/></observation>

</entryRelationship></observation>

</entry></section>

Coduri posibile din LOINC pentru metoda de stabilire a datei nasterii.

Code Description

11779-6 DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM LAST MENSTRUAL PERIOD

70000-4 DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM CLINICIANS PHYSICAL EXAM

11781-2 DELIVERY DATE-TMSTP-PT-^PATIENT-QN-US.COMPOSITE.ESTIMATED

70000-5 DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM DATE OF QUICKENING

70000-6 DELIVERY DATE-TMSTP-PT-^PATIENT-QN-ESTIMATED FROM DATE FUNDAL HEIGHT REACHES UMBILICUS

Narativ

<text><list>

<item><paragraph>Metoda: Ultrasunete</paragraph>

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<paragraph>Data control: 12.02.2007</paragraph><paragraph>Data probabila a nasterii: 27.07.2007</paragraph>

</item></list>

</text>

Istoric Menstruatie(Review of Systems)

DescriereAceasta sectiune contine o descriere a raspunsurilor date de catre pacient la un set de intrebari de rutina aspra functiilor organismului(menstruatie). Vezi http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.3.18

Elemente si atributeElemente Atribute Tip data R/M/O:cardinalitate DescriereComponent.section.code code CE M: 1..1 codul sectiunii:

<code code='10187-3' displayName='REVIEW OF SYSTEMS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

codeSystemcodeSystemNamedisplayName

component.section.title   TEXT   Titlul sectiuniicomponent.section.text   TEXT   Campul care este folosit pentru a afisa detaliile

acestei sectiuni in format text, pentru vizualizarisection.entry.observation.code Code CE M: 1..1 Revizuire sistem

DisplayNamecodeSystemcodeSystemName

section.entry.observation.value xsi:type TS, BL, PQ M: 1..1 Valoare in functie de cod   

component.section.entry.observat   text O: 0..1 Comentarii

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ion.textsection.entry.observation.effectiveTime

Value IVL_TS M: 1..1 Data si ora consultatiei.

Exemplu<component>

<section><code code='10187-3' displayName='REVIEW OF SYSTEMS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/><text> Text </text><entry>

<observation typeCode='OBS' moodCode='EVN'><code code=' ' displayName=' ' codeSystem='’’' codeSystemName=''/><text>’’</text><statusCode code='completed'/><effectiveTime value=' '/><value xsi:type=' ' />

</observation></entry>

</section></component>

APR H&P Review of Systems - Menstrual History Observation Codes Value Set 1.3.6.1.4.1.19376.1.5.3.1.1.16.5.5

Name Opt Type Units SNOMED CTDate of Last Menstrual Period R TS   21840007Menses Monthly R BL   364307006Prior Menses Date R TS   84292000Duration of Menstrual Flow

R PQ days 364306002Frequencyon Birth Control Pills at conception R BL   59261009Menarche R PQ  years 398700009hCG+ R TS   59433001

Fetal movement:

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<code code='iw-fetal-movement' displayName='MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

Narativ<text>

<table><col width="197" align="left" valign="top" /><col width="400" align="left" valign="top" /><thead>

<tr><th>Date / Time</th><th>7/2/2008 9:25:00 AM</th>

</tr></thead><tbody>

<tr><th>Date of Last Menstrual Period</th><td align="center">7/3/2008</td>

</tr><tr>

<th>Date of First Fetal Movement</th><td align="center">7/24/2008</td>

</tr><tr>

<th>Menses Monthly</th><td align="center">Yes</td>

</tr><tr>

<th>Prior Menses Date</th><td align="center">7/3/2008</td>

</tr><tr>

<th>Duration of Menstrual Flow Frequency</th><td align="center">1 days</td>

</tr><tr>

<th>On Birth Control Pills at conception</th><td align="center">Yes</td>

</tr><tr>

<th>Menarche</th><td align="center">2 years</td>

</tr><tr>

<th>Date of hCG+</th><td align="center">7/4/2008</td>

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</tr></tbody>

</table></text>

Consultatie prenatala

DescriereAceasta sectiune contine consultatiile prenatale efectuate de catre gravida. Vezi http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.11.2.2.2, http://wiki.ihe.net/index.php?title=APS_Example

Elemente si atributeElemente Atribute Tip data R/M/O:cardinalitate DescriereComponent.section.code code CE M: 1..1 codul sectiunii

<code code='70000-2' displayName='PREGNANCY VISIT SUMMARY-^PATIENT-FIND-PT-NAR'

codeSystemcodeSystemNamedisplayName

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codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

component.section.title   TEXT   Titlul sectiuniicomponent.section.text   TEXT   Campul care este folosit pentru a afisa detaliile

acestei sectiuni in format text, pentru vizualizarisection.entry.observation.code code CE M: 1..1 LOINC code 8348-5 – Greutatea inainte de sarcina

displayNamecodeSystemcodeSystemName

section.entry.observation.value xsi:type PQ, M: 1..1 Valoarea greutatii inainte de sarcinaUnitate: "kg"unit  

value  section.entry.observation.effectiveTime value TS O:0..1 Data stabilirii greutatii inainte de sarcina

       section.entry.organizer classCode   M:1..* Cate un astfel de element pentru fiecare consultatie

moodCode    section.entry.organizer.code Code CE M: 1..1 <code code='(xx-acog-battery)'

codeSystem='2.16.840.1.113883.6.1'/> DisplayNamecodeSystemcodeSystemName

section.entry.organizer.effectiveTime value TS M: 1..1 Data consultatiei

section.entry.organizer.component     M: 1..*Cate un astfel de element pentru fiecare tip de observatie

section.entry.organizer.component.observation.code

code CE M: 1..1 Tipul observatieidisplayNamecodeSystemcodeSystemName

section.entry.organizer.component.observation.value

xsi:type PQ, M: 1..1 ValoareCO

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BLED

section.entry.organizer.component.observation.text

  text O: 0..1 Comentarii

Tipuri de observatie

Name Opt Type Units Code Code SystemCorrected Week O PQ  Wk IW-CORRECTED-WEEK LOINC

BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED O PQ  Wk 3141-9 LOINC

Heart rate O PQ   364075005 SNOMED CTINTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN O PQ 8480-6

LOINC

INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN O PQ   8462-4

LOINC

FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE O PQ  Cm 11881-0 LOINC

Abdominal Circumference O PQ   IW-ABD-CIRC LOINC

MAF O BL IW-MAF LOINC

BCF O BL IW-BCF LOINC

Cervix Status O PQ IW-COLST LOINC

EDEMA-FIND-PT-^PATIENT-ORD O BL 44966-0 LOINC

Varix O PQ IW-VAR LOINC

HGB O PQ IW-HGB LOINC

HTC O PQ IW-HTC LOINC

Vaginal Bacterial Exam O PQ IW-EXBACVA LOINC

Urinary Sample O PQ IW-URO LOINC

Urinary Summary Modified O BL IW-SUMUM LOINC

TIME TO NEXT VISIT O PQ iw-time-to-next-appt LOINC

(comment field) O PQ 48767-8 LOINC

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Exemplu <component>

<section><id/><title>Visit Summary Flowsheet</title><text>

<table border='1'><thead>

<tr><td>Pre-pregnancy Weight</td>

</tr></thead><tbody>

<tr><td>220</td>

</tr></tbody>

</table><table border='1'>

<thead><tr>

<td colspan='19'>Visit Summary</td></tr><tr>

<th>Weeks Gestation</th><th>Fundal Height(cm)</th><th>Presentation</th><th>FHR</th><th>Fetal Movement</th><th>Preterm Labor Symptoms</th><th>Cervix Exam-Dilation</th><th>Cervix Exam-Effacement</th><th>Cervix Exam-Station</th><th>BP - Systolic</th><th>BP - Diastolic</th><th>Weight</th><th>Urine-Albumin</th><th>Urine-Glucose</th><th>Edema</th><th>Pain Scale (0-10)</th><th>Next Appt</th><th>Provider Initials</th><th>Comments</th>

</tr></thead><tbody>

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<tr ><td ID='WeeksGestation-1'>9</td><td ID='FundalHeight-1'></td><td ID='Presentation-1'>NULL^UNKNOWN</td><td ID='FHR-1'>Not Heard</td><td ID='Quickening-1'>no</td><td ID='PretermLabor-1'>no</td><td ID='CervixDil-1'>closed</td><td ID='CervixEff-1'>0</td><td ID='CervixSta-1'>unengaged</td><td ID='BPSystolic-1'>110</td><td ID='BPDiastolic-1'>60</td><td ID='Weight-1'>218</td><td ID='UrineAlbumin-1'>Neg</td><td ID='UrineGlucose-1'>NL</td><td ID='Edema-1'>None</td><td ID='PainScale-1'>0</td><td ID='NextAppt-1'>2 Weeks</td><td ID='ProviderInitials-1'>DD</td><td ID='Comments-1'>33 yo G1 IVF implantation 10/10 here for IP...</td>

</tr><tr>

<td ID='WeeksGestation-2'>11</td><td ID='FundalHeight-2'>12</td><td ID='Presentation-2'>NULL^UNKNOWN</td><td ID='FHR-2'>Not Heard</td><td ID='Quickening-2'>no</td><td ID='PretermLabor-2'>no</td><td ID='CervixDil-2'></td><td ID='CervixEff-2'></td><td ID='CervixSta-2'></td><td ID='BPSystolic-2'>110</td><td ID='BPDiastolic-2'>63</td><td ID='Weight-2'>217</td><td ID='UrineAlbumin-2'>Neg</td><td ID='UrineGlucose-2'>NL</td><td ID='Edema-2'>None</td><td ID='PainScale-2'>0</td><td ID='NextAppt-2'>4 Weeks</td><td ID='ProviderInitials-2'>ER</td><td ID='Comments-2'>11.3wk by LMP c/w 6.5 wk U/S. No FHT tod...</td>

</tr></tbody>

</table></text>

<!-- pre-pregancy weight -->

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<entry><observation classCode='OBS' moodCode='EVN'>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='23e87612-1000-11dc-8314-0800200c9a66'/><code code='8348-5'

displayName='BODY WEIGHT^PRE PREGNANCY-MASS-PT-QN-MEASURED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#PrePregWeight-1'/>

</text><statusCode code='completed'/><effectiveTime value='200609211242-08'/><value xsi:type='PQ' />

</observation></entry>

<!-- panel date 11/29/06 --><entry>

<organizer classCode='BATTERY' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/><id root='4d878166-1000-11dc-8314-0800200c9a66'/><code code='(xx-acog-battery)'

displayName='ACOG Summary Visit Battery---PT--'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<statusCode code='completed'/><effectiveTime value='200611291242-08'/><author typeCode='AUT'>

<!-- Provider Initials --><time value='20061129'/><!-- Visit Date --><assignedAuthor>

<id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c' /><!-- links to header element -->

</assignedAuthor></author>

<!-- Weeks Gestation --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4d878167-1000-11dc-8314-0800200c9a66'/><code code='11884-4'

displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#WeeksGestation-1'/>

</text>

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<statusCode code='completed'/><value xsi:type='PQ' unit='wk' value='9'/>

</observation></component>

<!-- Fundal Height (cm) --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4d878168-1000-11dc-8314-0800200c9a66'/><code code='11881-0'

displayName='FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#FundalHeight-1'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Presentation (value set) --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4d878169-1000-11dc-8314-0800200c9a66'/><code code='11876-0'

displayName='FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Presentation-1'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Fetal Heart Rate --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='694f9f23-ed2f-4534-89c2-3bf4ccb6581e'/><code code='11948-7'

displayName='HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#FHR-1'/>

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</text><statusCode code='completed'/><value xsi:type='PQ'></value>

</observation></component>

<!-- Fetal Movement/Quickening --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='b7c8d2dc-405f-4cb1-8d53-9395e414f3a5'/><code code='(xx-fetal-movement)'

displayName='MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Quickening-1'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Preterm Labor Symptoms --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4e58accc-2668-4329-b9af-d7be78f86af4'/><code code='(xx-SS-Preterm-Labor)'

displayName='PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#PretermLabor-1'/>

</text><statusCode code='completed'/><value xsi:type='BL'/>

</observation></component>

<!-- Cervix Exam - Dilation --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/><code code='(xx-cerv-dil-palp)'

displayName='DILATION-LEN-PT-CERVIX-QN-PALPATION'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />

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<text><reference value='#CervixDil-1'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Cervix Exam - Effacement --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/><code code='11867-9'

displayName='EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION 'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#CervixEff-1'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Cervix Exam - Station --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/><code code='11961-0'

displayName='LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#CervixSta-1'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Blood Pressure - Systolic --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/><code code='8480-6'

displayName='INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN'

Page 127: Ghid Implementare CDA

codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' /><text>

<reference value='#BPSystolic-1'/></text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Blood Pressure - Diastolic --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/><code code='8462-4'

displayName='INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#BPDiastolic-1'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Weight --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='22c470bc-db0a-4b66-a9e6-d2fac31db930'/><code code='3141-9'

displayName='BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Weight-1'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Urine - Albumin --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/><code code='1753-3'

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displayName='ALBUMIN-ACNC-PT-UR-ORD'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#UrineAlbumin-1'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Urine - Glucose --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/><code code='2349-9'

displayName='GLUCOSE-ACNC-PT-UR-ORD'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#UrineGlucose-1'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Edema --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='3b3fb536-e9ad-47f4-8199-c58c017b6186'/><code code='44966-0'

displayName='EDEMA-FIND-PT-^PATIENT-ORD'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Edema-1'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Pain Scale (1-10) --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='78e08791-af8c-4b05-98a0-8949eae03e59'/>

Page 129: Ghid Implementare CDA

<code code='38208-5'displayName='PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#PainScale-1'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Next Appointment --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4fb5998e-11e4-416e-ab2c-e5b6f7c424a4'/><code code='(xx-time-to-next-appt)'

displayName='TIME TO NEXT VISIT-'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#NextAppt-1'/>

</text><statusCode code='completed'/><value xsi:type='ED'/>

</observation></component>

<!-- Comments --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='e53fec4b-f3c0-486e-b4e0-22fb65e7f547'/><code code='48767-8'

displayName='(comment field)'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Comments-1'/>

</text><statusCode code='completed'/><value xsi:type='ED'/>

</observation></component>

</organizer></entry>

<!-- panel date 4/26/07 -->

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<entry><organizer classCode='BATTERY' moodCode='EVN'>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2'/><id root='4d878166-1000-11dc-8314-0800200c9a66'/><code code='(xx-acog-battery)'

displayName='ACOG Summary Visit Battery---PT--'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<statusCode code='completed'/><effectiveTime value='200611291242-08'/><author typeCode='AUT'>

<!-- Provider Initials --><time value='20061129'/><!-- Visit Date --><assignedAuthor>

<id root='20cf14fb-b65c-4c8c-a54d-b0cca834c18c' /><!-- links to header element -->

</assignedAuthor></author>

<!-- Weeks Gestation --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4d878167-1000-11dc-8314-0800200c9a66'/><code code='11884-4'

displayName='GESTATIONAL AGE-TIME-PT-^FETUS-QN-CLINICAL.ESTIMATED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#WeeksGestation-2'/>

</text><statusCode code='completed'/><value xsi:type='PQ' unit='d' value='11'/>

</observation></component>

<!-- Fundal Height (cm) --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4d878168-1000-11dc-8314-0800200c9a66'/><code code='11881-0'

displayName='FUNDAL HEIGHT-LEN-PT-UTERUS-QN-TAPE MEASURE'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#FundalHeight-2'/>

</text><statusCode code='completed'/>

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<value xsi:type='PQ'/></observation>

</component>

<!-- Presentation (value set) --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4d878169-1000-11dc-8314-0800200c9a66'/><code code='11876-0'

displayName='FETAL PRESENTATION-TYPE-PT-PELVIS-NOM-PALPATION'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Presentation-2'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Fetal Heart Rate --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='694f9f23-ed2f-4534-89c2-3bf4ccb6581e'/><code code='11948-7'

displayName='HEART RATE-NRAT-PT-^FETUS-QN-US.MEASURED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#FHR-2'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Fetal Movement/Quickening --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='b7c8d2dc-405f-4cb1-8d53-9395e414f3a5'/><code code='(xx-fetal-movement)'

displayName='MOVEMENT-FIND-PT-^FETUS-ORD-PATIENT REPORTED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Quickening-2'/>

</text>

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<statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Preterm Labor Symptoms --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4e58accc-2668-4329-b9af-d7be78f86af4'/><code code='(xx-SS-Preterm-Labor)'

displayName='PRETERM LABOR SYMPTOMS-FIND-PT-^PATIENT-QL-CLINICAL JUDGEMENT'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#PretermLabor-2'/>

</text><statusCode code='completed'/><value xsi:type='BL'/>

</observation></component>

<!-- Cervix Exam - Dilation --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/><code code='(xx-cerv-dil-palp)'

displayName='DILATION-LEN-PT-CERVIX-QN-PALPATION'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />

<text><reference value='#CervixDil-2'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Cervix Exam - Effacement --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/><code code='11867-9'

displayName='EFFACEMENT-PRCTL-PT-CERVIX-ORD-PALPATION 'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#CervixEff-2'/>

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</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Cervix Exam - Station --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='a53c8593-d822-4722-9aa6-b7e74debc6b0'/><code code='11961-0'

displayName='LONG AXIS-LEN-PT-CERVIX-QN-US.MEASURED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#CervixSta-2'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Blood Pressure - Systolic --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/><code code='8480-6'

displayName='INTRAVASCULAR SYSTOLIC-PRES-PT-ARTERIAL SYSTEM-QN'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />

<text><reference value='#BPSystolic-2'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Blood Pressure - Diastolic --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4773a849-db3f-4e21-b3a9-7b5b467d91e9'/><code code='8462-4'

displayName='INTRAVASCULAR DIASTOLIC-PRES-PT-ARTERIAL SYSTEM-QN'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text>

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<reference value='#BPDiastolic-2'/></text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Weight --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='22c470bc-db0a-4b66-a9e6-d2fac31db930'/><code code='3141-9'

displayName='BODY WEIGHT-MASS-PT-^PATIENT-QN-MEASURED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Weight-2'/>

</text><statusCode code='completed'/><value xsi:type='PQ'/>

</observation></component>

<!-- Urine - Albumin --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/><code code='1753-3'

displayName='ALBUMIN-ACNC-PT-UR-ORD'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#UrineAlbumin-2'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Urine - Glucose --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='13599834-be6f-44fc-9db1-e5dc6a79d565'/><code code='2349-9'

displayName='GLUCOSE-ACNC-PT-UR-ORD'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

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<text><reference value='#UrineGlucose-2'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Edema --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='3b3fb536-e9ad-47f4-8199-c58c017b6186'/><code code='44966-0'

displayName='EDEMA-FIND-PT-^PATIENT-ORD'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Edema-2'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Pain Scale (1-10) --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='78e08791-af8c-4b05-98a0-8949eae03e59'/><code code='38208-5'

displayName='PAIN SEVERITY-FIND-PT-^PATIENT-ORD-REPORTED'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#PainScale-2'/>

</text><statusCode code='completed'/><value xsi:type='CO'/>

</observation></component>

<!-- Next Appointment --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='4fb5998e-11e4-416e-ab2c-e5b6f7c424a4'/><code code='(xx-time-to-next-appt)'

displayName='TIME TO NEXT VISIT-'

Page 136: Ghid Implementare CDA

codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/><text>

<reference value='#NextAppt-2'/></text><statusCode code='completed'/><value xsi:type='ED'/>

</observation></component>

<!-- Comments --><component>

<observation classCode='OBS' moodCode='EVN'><templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><id root='e53fec4b-f3c0-486e-b4e0-22fb65e7f547'/><code code='48767-8'

displayName='(comment field)'codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text><reference value='#Comments-2'/>

</text><statusCode code='completed'/><value xsi:type='ED'/>

</observation></component>

</organizer></entry>

</section></component>

Narativ<text>

<paragraph>Pre-pregnancy Weight: 220</paragraph><paragraph>Visit Summary:</paragraph><table>

<tbody><tr>

<th>Weeks Gestation</th><th>Fundal Height(cm)</th><th>Presentation</th><th>FHR</th><th>Fetal Movement</th><th>Preterm Labor Symptoms</th><th>Cervix Exam-Dilation</th><th>Cervix Exam-Effacement</th>

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<th>Cervix Exam-Station</th><th>BP - Systolic</th><th>BP - Diastolic</th><th>Weight</th><th>Urine-Albumin</th><th>Urine-Glucose</th><th>Edema</th><th>Pain Scale (0-10)</th><th>Next Appt</th><th>Provider Initials</th><th>Comments</th>

</tr>

<tr ><td ID='WeeksGestation-1'>9.3</td><td ID='FundalHeight-1'></td><td ID='Presentation-1'>NULL^UNKNOWN</td><td ID='FHR-1'>Not Heard</td><td ID='Quickening-1'>no</td><td ID='PretermLabor-1'>no</td><td ID='CervixDil-1'>closed</td><td ID='CervixEff-1'>0</td><td ID='CervixSta-1'>unengaged</td><td ID='BPSystolic-1'>110</td><td ID='BPDiastolic-1'>60</td><td ID='Weight-1'>218</td><td ID='UrineAlbumin-1'>Neg</td><td ID='UrineGlucose-1'>NL</td><td ID='Edema-1'>None</td><td ID='PainScale-1'>0</td><td ID='NextAppt-1'>2 Weeks</td><td ID='ProviderInitials-1'>DD</td><td ID='Comments-1'>33 yo G1 IVF implantation 10/10 here for IP...</td>

</tr><tr>

<td ID='WeeksGestation-2'>11.4</td><td ID='FundalHeight-2'>12</td><td ID='Presentation-2'>NULL^UNKNOWN</td><td ID='FHR-2'>Not Heard</td><td ID='Quickening-2'>no</td><td ID='PretermLabor-2'>no</td><td ID='CervixDil-2'></td><td ID='CervixEff-2'></td><td ID='CervixSta-2'></td><td ID='BPSystolic-2'>110</td><td ID='BPDiastolic-2'>63</td><td ID='Weight-2'>217</td>

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<td ID='UrineAlbumin-2'>Neg</td><td ID='UrineGlucose-2'>NL</td><td ID='Edema-2'>None</td><td ID='PainScale-2'>0</td><td ID='NextAppt-2'>4 Weeks</td><td ID='ProviderInitials-2'>ER</td><td ID='Comments-2'>11.3wk by LMP c/w 6.5 wk U/S. No FHT tod...</td>

</tr></tbody>

</table></text>

Acuze

DescriereAceasta sectiune contine acuzele pacientului. Vezi http://wiki.ihe.net/index.php?title=Chief_Complaint

Elemente si atributeElemente Atribute Tip

dataR/M/O: cardinalitate

Descriere

Component.section.code code CE M: 1..1 Codul sectiunii:<code code='10154-3' displayName='CHIEF COMPLAINT' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

codeSystemcodeSystemNamedisplayName

component.section.title   TEXT   Titlul sectiuniicomponent.section.text   TEXT   Descriere acuze

Page 139: Ghid Implementare CDA

component.section.observation.code code codeSystem codeSystemName displayName

Tipul observatiei: Complaint

component.section.observation.effectiveTime dateTimeValue IVL_TS Data inceput acuzacomponent.section.observation.text TEXT M: 1..1 Acuze

Exemplu<section>

<code code='10154-3' displayName='CHIEF COMPLAINT' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text>Text

</text><entry>

<observation typeCode='OBS' moodCode='EVN'><code code='409586006' displayName='Complaint'codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'>

<effectiveTime value=' '/><text>’Acuza’</text>

</observation></entry>

</section>

Narativ

<text><list>

<item><paragraph>Durere spate</paragraph><paragraph>Observatii: la aplecare</paragraph>

</item></list>

</text>

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Concediu medical

DescriereAceasta sectiune contine certificatele pentru concedii medicale.

Elemente si atributeElemente Atribute Tip data R/M/O:

cardinalitateDescriere

Component.section.code code CE M: 1..1 codul sectiunii:<code code=’70000-3’ displayName='Sick leave' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

codeSystemcodeSystemNamedisplayName

component.section.title   TEXT   Titlul sectiuniicomponent.section.text   TEXT   Descriere certificateComponent.section.entry.act.id root II M: 1..1 Seria si numarul certificatului

extension  Component.section.entry.act.code code CD M: 1..1 Tipul concediului

ValueSet: 3.3.3.3.98 - HM3TipConcediucodeSystemcodeSystemNamedisplayName

Component.section.entry.act.effectiveTime

dateStart IVL_TS O: 1..1 Data de inceput si de sfarsit a concediului medicaldateEndvalue Data acordarii CM

Component.section.entry.act.priorityCode.code

code CE O: 0..1 Urgenta medico-chirurgicalaValueSet: 3.3.3.3.100 – HM3TipUrgentaConcedii

codeSystemcodeSystemNamedisplayName

component.section.entry.act.reference.externalDocument.id

root II O: 0..2 Referinta catre un diagnostic din sectiunea de diagnostice (diagnostic amb/int)ValueSet: icd10

extension

component.section.entry.act.reference.externalAct.id

RootExtension

II O: 0..1 Seria si numarul documentului initial, in cazul in care certificatul se acorda in continuare.

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component.section.entry.act.reference.externalObservation.text

text ED O: 0..1 Sectia spitalului unde se interneaza pacientul.

component.section.entry.act.entryRelationship

typeCode 

 

O: 0..4 -SUBJ = in cazul in care concediul medical se acorda la externareobservation.code:<code code='373864002' displayName='Outpatient' codeSystem=' 2.16.840.1.113883.6.96' codeSystemName='SNOMED CT' />

- REFR = referinta catre boala infectioasaobservation.code:<code code=' 35500006' displayName='Contagious disease' codeSystem=' 2.16.840.1.113883.6.96' codeSystemName='SNOMED CT' />

-CAUS = indemnizatia-GEVL = aviz expertObservation.code:<code displayName="Aviz expert" codeSystemName="LOINC" code="34134-7" codeSystem="2.16.840.1.113883.6.1" />

component.section.entry.act.entryRelationship.observation.reference.externalDocument.id

Root II 0: 0..1 Diagnostic la externare - referinta catre sectiunea de diagnosticeValueSet: icd10

extension

component.section.entry.act.entryRelationship.observation.effectiveTime

dateStart IVL_TS O: 0..1 Data de inceput si de sfarsit a valabilitatii concediului medical la externaredateEnd

value Data acordarii CM la externare

component.section.entry.act.entryRelationship.observation.value

codecodeSystemcodeSystemNamedisplayName

CD O: 0..1 Boala infectioasa ValueSet: 3.3.3.3.97 – HM3TipBoalaConcedii

component.section.entry.act.entryRelationship.observation.code

codecodeSystemcodeSystemName

CD R: 1..1 Indemnizatia de asigurari sociale de sanatateValueSet: 3.3.3. 3.99 – HM3TipIndemnizatieConcedii

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displayNamecomponent.section.entry.act.entryRelationship.observation.id

rootextension

II O: 0..1 Identificator pt aviz expertroot: (parafa-expert, numar-aviz)

Exemplu<section>

<code code='70000-3' displayName='Sick leave' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

<text>Text

</text><entry>

<act><id root='COD S' extension='1111111111'/><code code='' displayName='' codeSystem='' codeSystemName='' /><effectiveTime xsi:type="PIVL_TS" value="">

<low value=""><high value="">

</effectiveTime><priorityCode code='' displayName='' codeSystem='' codeSystemName='' /><reference>

<externalDocument><id root="" extension="" />

</externalDocument><externalAct>

<id root="" extension="" /></externalAct ><externalObservation>

<text>’’</text></externalObservation>

</reference><entryRelationship typeCode='SUBJ'>

<observation typeCode='OBS' moodCode='EVN'><code code='373864002' displayName='Outpatient' codeSystem=' 2.16.840.1.113883.6.96'

codeSystemName='SNOMED CT' /><effectiveTime xsi:type="PIVL_TS" value="">

<low value=""><high value="">

</effectiveTime><reference>

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<externalDocument><id root="" extension=""/>

</externalDocument></reference>

</observation></entryRelationship><entryRelationship typeCode='REFR'>

<code code=' 35500006' displayName='Contagious disease' codeSystem=' 2.16.840.1.113883.6.96' codeSystemName='SNOMED CT' />

<observation typeCode='OBS' moodCode='EVN'><reference>

<externalDocument><id root="" extension=""/>

</externalDocument></reference>

</observation></entryRelationship>

</act></entry>

</section>

Narativ<text>

<table><tbody>

<tr><th>Nr. crt.</th><th>Serie</th><th>Numar</th><th>Urgenta</th><th>Cod boala infectioasa</th><th>Cod indemnizatie</th><th>Data acordarii</th><th>Data inceput amb/int</th><th>Data sfarsit amb/int</th><th>Data inceput la ext</th><th>Data sfarsit la ext</th><th>Cod diagnostic amb/int</th><th>Cod diagnostic la ext</th>

</tr><tr>

<td>1</td><td>COD S</td><td>11111111</td><td>107</td><td></td>

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<td>06</td><td>06.03.2007</td><td>07.03.2007</td><td>12.03.2007</td><td>13.03.2007</td><td>20.03.2007</td><td>797</td><td>989</td>

</tr></tbody>

</table></text>

Lapte praf

DescriereAceasta sectiune contine prescrierile pentru lapte praf.

Elemente si atribute

Elemente Atribute Tip data

R/M/O: cardinalitate

Descriere

Component.section.code codecodeSystemcodeSystemNamedisplayName

CE M: 1..1 Codul care identifica sectiunea de prescriere lapte praf:<code codeSystemName="LOINC" code="iw-pwdmilk" displayName=”PowderedMilk” codeSystem="2.16.840.1.113883.6.1" />

component.section.title TEXT M: 1..1 Titlul sectiunii component.section.text TEXT M: 1..1 Campul care este folosit pentru a afisa datele introduse intr-o forma

usor citibilaComponent.section.entry.substanceAdministration

classCodemoodCode

M:1..* O linie din prescrierea de lapte praf. classCode = SBADMmoodCode = INT

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component.section.entry.substanceAdministration.text

TEXT O:0..1 Comentarii asociate liniei curente din prescriere

component.section.entry.substanceAdministration.approachSiteCode

codecodeSystemcodeSystemNamedisplayName

CE O:0..1 Tipul de alimentatie (VS: Alimentatie)

substanceAdministration.preconditionCollection.criterion.code

codecodeSystemcodeSystemNamedisplayName

CE O:0..1 Criteriul de selectie (VS: CriteriuSelectie)

component.section.entry.substanceAdministration.doseQuantity

valueunit

PQ O:0..1 Cantitatea prescrisa

substanceAdministration.effectiveTime

value SXCM_TS

O:0..1 Data prescrierii

substanceAdministration.preconditionCollection.criterion.value

PQ O:0..1 Greutate copil

component.section.entry substanceAdministration.entryRelationship.supply.quantity

value PQ O:0..1 Cantitatea eliberata

substanceAdministration.entryRelationship.supply.effectiveTime

value SXCM_TS

O:0..* Data eliberarii

component.section.entry .observation

classcodemoodcode

M:1..1 Contine detalii din header( data intrarii si data iesirii din program)classCode = CASE;moodCode = INT;

component.section.entry .observation.DateStart, DateEnd

value IVL_TS O:0..* Data intrarii si data iesirii din program

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Exemplu <component>

<section><code codeSystemName="LOINC" code="iw-pwdmilk" codeSystem="2.16.840.1.113883.6.1" /><title>Prescriere lapte praf</title><entry>

<observation classCode="CASE" moodCode="INT"><effectiveTime>

<low value="20080901000000.0000+03" /><high value="20080927000000.0000+03" />

</effectiveTime></observation>

</entry><entry>

<substanceAdministration classCode="SBADM" moodCode="INT"><text>note 1</text><effectiveTime value="20080920000000.0000+03" /><approachSiteCode displayName="Mixt" code="MIX" codeSystem="1.1.1.3" /><doseQuantity value="2" /><entryRelationship typeCode="COMP">

<supply moodCode="EVN"><effectiveTime value="20080926000000.0000+03" /><quantity value="2" />

</supply></entryRelationship><precondition>

<criterion><code displayName="Copii sănătoşi la care se constată o creştere nesatisfăcătoare

(insuficienţei cantitative a laptelui matern)" code="b" codeSystem="1.1.1.2" /><value xsi:type="PQ" unit="kg" value="35" />

</criterion></precondition>

</substanceAdministration></entry>

</section></component>

Narativ<text>

<content>Data intrării în program: 01.09.2008</content><content>

<br /></content><content>Data ieşirii din program: 27.09.2008</content><list>

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<item><paragraph>Criteriu de selecţie: Copii sănătoşi la care se constată o creştere nesatisfăcătoare (insuficienţei

cantitative a laptelui matern)</paragraph><paragraph>Greutate copil la data prescrierii: 35 kg</paragraph><paragraph>Alimentaţie: Mixt</paragraph><paragraph>Cantitate prescrisă: 2</paragraph><paragraph>Data prescrierii: 20.09.2008</paragraph><paragraph>Cantitate eliberată: 2</paragraph><paragraph>Data eliberării: 26.09.2008</paragraph><paragraph>

<content>Comentarii: </content><content>note 1</content>

</paragraph></item><item>

<paragraph>Criteriu de selecţie: Mame care prezintă contraindicaţii ale alăptării (boli grave, tratamente incompatibile)</paragraph>

<paragraph>Greutate copil la data prescrierii: 36 kg</paragraph><paragraph>Alimentaţie: Artificial</paragraph><paragraph>Cantitate prescrisă: 1</paragraph><paragraph>Data prescrierii: 22.09.2008</paragraph><paragraph>Cantitate eliberată: 13</paragraph><paragraph>Data eliberării: 23.09.2008</paragraph><paragraph>

<content>Comentarii: </content><content>note 2</content>

</paragraph></item>

</list></text>

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Recoltare probe

DescriereAceasta parte este inclusa in sectiunea de laborator si face referire la probele recoltate in vederea efectuarii analizelor de laborator.

Elemente si atribute

Elemente Atribute Valoare Tip data

R/M/O: cardinalitate

Descriere

Act classCode ACT M:1..1moodCode EVN

Act.templateId Root 1.3.6.1.4.1.19376.1.3.1.2

II M:1..1 Valoare obligatorie si fixa ce reprezinta template-ul pentru actul de colectare de probe

Act.code Code "33882-2 CE M:1..1 Codul LOINC reprezentand actul de colectare de probeEx: <code code="33882-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Specimen Collection"/>

CodeSystem 2.16.840.1.113883.6.1

CodeSystemName LOINCDisplayName Specimen

collectionAct.effectiveTime Value TS M:1..1 Data si ora colectarii probelor, completata din interfataAct.Specimen typeCode SPC O:0..*Act.Specimen.SpecimenRole classCode SPEC M:1..1Act.specimen.specimenRole.id Root II M:1..1 Identificator unic pentru proba (“as referenced by the

Placer application, the Filler application, or both”).Ex: <id root="InfoWorld.Specimen.TEST" extension="AA0002.VRC"/>

extension

Act.specimen.specimenRole.specimenPlayingEntity.code

Code CE M:1..1 The Code that corresponds to the Name of the precise nature of the entity that will be the source material for the observationVocabulary: SpecimenCollection

CodeSystem 69.1.1.1CodeSystemNameDisplayName

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Act.specimen.specimenRole.specimenPlayingEntity.quantity

Value PQ M:1..1 Cantitatea de probe (i.e.. numarul de eprubete)

Act.Participant typeCode PRF Reprezinta mediculcontextControlCode AN

Act.Participant.ParticipantRole classCode LICAct.Participant.ParticipantRole.Id

root ConsultantRegNo

Root pentru codul de parafa al medicului

extension Codul de parafa al mediculuiAct.Participant.ParticipantRole.Id.playingEntityAct.Participant.ParticipantRole.Id.playingEntity.name

PN Numele medicului

Exemplu<act classCode="ACT" moodCode="EVN">

<templateId root="1.3.6.1.4.1.19376.1.3.1.2"/> <code code="33882-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Specimen Collection"/><effectiveTime value="" /><specimen typeCode="SPC">

<specimenRole classCode="SPEC"><id root="InfoWorld.Specimen.TEST" extension=""/><specimenPlayingEntity>

<code code="BLD" codeSystem="69.1.1.1" codeSystemName="HL7" displayName="Blood"/><quantity value="3"/>

</specimenPlayingEntity></specimenRole>

</specimen><participant typeCode="PRF" contextControlCode="AN">

<participantRole classCode="LIC"> <id root="InfoWorld" extension="d392e853-6fca-4aca-9eb4-ed637747555a" /> <id root="ConsultantRegNo" extension="252525" /> <playingEntity>

<name> <family partType="FAM">MED</family> <given partType="GIV">AMBULATOR</given>

</name> </playingEntity>

</participantRole></participant>

</act>

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Anexe

Pharmacy

Precizari implemenentare sectiuni prescriere si eliberare medicamente- Se foloseste LOINC pentru coduri de sectiune

o 29305-0 pentru MEDICATION PRESCRIBED (order request)o 29304-3 pentru MEDICATION DISPENSED (order result)

- Cele doua sectiuni de mai sus sunt disjuncte- Se folosesc doua codificari pentru statusuri: statusCode si moodCode

o Acestea se folosesc in tagurile: substanceAdministration

Acest tag reprezinta o linie de pe cerere Statusul este dat de atributul moodCode si de tagul statusCode Starile sunt:

o Nou: statusCode new si moodCode RQO. In acest caz exista un singur supply cu moodCode RQOo In lucru: statusCode active si moodCode PRMS. In acest caz exista mai mult de un tag supply. Primul

reprezentand cererea initiala, iar urmatoarele cantitatile care vor fi dispensateo Validat: statusCode completed si moodCode EVN. Ca mai sus in ce priveste tagurile supply, cu

precizarea ca in aceasta situatie actiunea este incheiatao Anulat: statusCode cancelled. In acest caz orice informatie din moodCode si din tagul/tagurile de supply

este irelevanta supply

Incapsulat in substanceAdministration Incapsuleaza cantitatile manipulate in cerere Primul supply dintr-un substanceAdministration *trebuie* sa fie cu moodCode RQO si reprezinta cererea initiala

de medicament. Medicament incapsulat in tagul manufacturedProduct. Pe acest tag de supply statusCode este ignorat

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Urmatoarele supply reprezinta medicamentele in curs de dispensare sau dispensate (pentru o cerere de un medicament se pot dispensa mai multe cantitati, eventual de pe loturi diferite)

Stari supply dispense:o In lucru: statusCode active si moodCode PRMSo Validat: statusCode completed si moodCode EVN

Tagul supply contine un tag product care contine la randul sau un tag manufacturedProduct, identic ca structura cu cel din tagul substanceAdministration, care contine informatii despre medicamentul dispensat. Aceasta informatie este folositoare mai ales cand se elibereaza alt medicamente decat cel prescris.

o Tagul statusCode are precedenta asupra tagului moodCode

Precizari fluxuri procesare sectiuni prescriere si eliberare medicamente:- Flux normal:

o Se primeste un order cu medicamentele prescrise/ceruteo Se decide ca orderul sa fie procesat pe un anumit dispense, singur sau impreuna cu alte ordere.

Medicamentele de pe order sunt trecute pe starea „in lucru” (PRMS). o Se pregateste eliberarea de medicamente pentru cererea in lucru pe eliberarea curenta in functie de stocurile existente.

Farmacistul poate decide eliberarea altor medicamente decat a celor prescrise, si a altor cantitati.o Se incheie procesarea eliberarii trecand-o in starea de VALIDA. Din acel moment medicamentele pot fi distribuite efectiv pe

sectie. Se creeaza un order response, in baza order request initial si care contine pe langa medicamentele cerute si

medicamentele eliberate, in taguri SUPPLY suplimentare (pe langa cele RQO initiale), si medicamentele sunt puse in starea „eliberate” (EVN).

Medicamentele dispensate de pe orderul initial sunt trecute in starea „eliberate” (EVN). Daca toate medicamentele sunt fie eliberate fie anulate atunci orderul initial si response-ul sau sunt puse pe starea

„incheiate”. In caz ca un order este prelucrat pe mai multe eliberari, atunci „incheierea” acestuia si a response aferent se face cand toate medicamentele de pe acesta au fost prelucrate pe o eliberare.

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Bilete de trimitere

Precizari implemenentare bilete de trimitere primite- Seria si nr biletului: sectiunea „Reason for visit”, in id- Free-text de pe biletul de trimitere: sectiunea „Reason for visit”, in narativ- Medic trimitator:

o encompassing Encounter, participant cu tip=referrer :encompassingEncounter.encounterParticipant[@typeCode= "REF"].assignedEntity.assignedPerson

o codul de parafa al medicului este un id pt assignedEntity, cu root= Cod-parafao campul code pentru assignedEntity este "PROV" din codingSystemul "RoleClass" ( healthcare provider )o specialitatea medicului trimitator este un qualifier pentru campul code de mai sus, avand name=”specialitatea medicala” (code=

"394658006" din Snomed) si value=un cd reprezentand specialitateao casa de asigurari a medicului trimitator este un qualifier pentru campul code de mai sus, cu name fiind code="UNDWRT" din

codingSystem-ul RoleClass, si value=un cd reprezentand casa de asigurari- Data trimiterii: data participarii medicului trimitator la encounter (encounterParticipant.time.low)- Unitate trimitatoare: representedOrganization pentru medicul trimitator- Contractul medicului/unitatii trimitator: pentru representedOrganization de mai sus, un id cu root= Nr-contract-casa, extension=nr

contractului, assigningAuthorityName=numele casei de asigurari- Diagnosticul de trimitere (prezumtiv): sectiunea evaluare, diagnostic cu tip = diagnostic de trimitere- „Programul National de Sanatate” :

o campul code pentru component.section.code este „HM3PNS” din codingSystemul „LOINC”, iar campul displayName este „Programul National de Sanatate”;

o Component.section.entry.observation.code va fi completat cu codul in care se specifica tipul „Programului National de Sanatate” pentru care a fost emis biletul din codeSystemul HM3NHP.

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Precizari implementare bilete de trimitere emise- Seria si nr biletului: sectiunea „Reason for referral”, in id- Free-text de pe biletul de trimitere: sectiunea „Reason for referral”, in narativ- Medic trimitator: aceleasi detalii ca la medicul trimitator pt biletele primite, pentru un encounterParticipant cu typeCode=”ATND”- Unitatea trimitatoare: locatia+organizatia din encompassingEncounter- Contractul medicului/unitatii: pentru organizatia de mai sus, un id cu root= Nr-contract-casa, extension=nr contractului,

assigningAuthorityName=numele casei de asigurari- Data biletului: data documentului clinic- Nr registru consultatii : un id de pe encompassingEncounter, cu root= "Reg-no"- Diagnostic prezumtiv (de trimitere) : sectiunea evaluare, diagnostic cu tip = diagnostic de trimitere (referit in sectiunea Reason-for-referral)- Diagnostice secundare : sectiunea evaluare, diagnostice cu tip = diagnostic secundar (referite in sectiunea Reason-for-referral)- Unitatea+medicul la care se face trimiterea: in intendedRecipient, medicul in informationRecipient, unitatea in receivedOrganization- Specialitatea la care se face trimiterea: pt receivedOrganization de mai sus, in code-ul lui asOrganizationPartOf- investigatiile paraclinice de pe biletul de trimitere: in sectiunea Cerere de laborator, proceduri cu moodCode=intent- investigatiile imagistice de pe biletul de trimitere: in sectiunea Cerere imagistica, proceduri cu moodCode=intent- alte investigatii de pe biletul de trimitere: in sectiunea Proceduri, proceduri cu moodCode=intent


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