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Ghid implementare CDAVersion: 1.11
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
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>
</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>
</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
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>
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>
</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 = ""/>
</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
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
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
.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>
</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>
</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.
<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
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">
<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..*
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"
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
<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" />
<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>
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
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>
<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" />
<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" />
<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
<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>
</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>
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
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>
<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>
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
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
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
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" />
</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" />
</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>
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
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
.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"/>
<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>
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>
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
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>
<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>
<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>
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
.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">
<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>
<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
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>
<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>
<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>
<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>
<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>
</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 />
</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>
Rezultate laborator
Descriere
Aceasta sectiune contine rezultatele analizelor trimise de catre laborator.Referinta: http://wiki.ihe.net/index.php?title=PCC_TF-1/PHLAB
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
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
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.
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
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 " />
<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>
</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>
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
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>
<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>
Bilet de trimitere emis
Descriere
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" />
<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>
<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>
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
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 & Adverse Reactions</title><text>
<list><item>
<content styleCode="Bold">Diagnostic probabil: Adverse reaction to drug – codeine . </content><content>Manifestare: Pruritis, Moderat</content>
</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>
</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
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
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" />
<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>
</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
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
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>
<!-- 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>
<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>
<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>
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
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>
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>
<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>
<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>
</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" />
</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" />
<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>
</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">
<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>
<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>
<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
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'
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>
<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
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:
<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>
</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
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
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
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>
<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 -->
<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>
<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'/>
</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' />
<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'
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'
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'/>
<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 -->
<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'/>
<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>
<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'/>
</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>
<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'/>
<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-'
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>
<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>
<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
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>
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.
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
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>
<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>
<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
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
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>
<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>
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
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>
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
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.
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.
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