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draft Template  XeH Clinical Information

Id 2.16.840.1.113883.2.51.10.61 Effective Date 2022‑03‑17 11:51:55
Status draft Draft Version Label DICOM-20150324
Name XeHClinicalInformation Display Name XeH Clinical Information
Description Clinical details about the case such as presenting signs and symptoms, past clinical history, the overall condition of the patient, etc
Context Parent nodes of template element with id 2.16.840.1.113883.2.51.10.61
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 4 templates
Uses as Name Version
1.2.840.10008.9.7 Containment draft Request (DICOM-20150324) DYNAMIC
1.2.840.10008.9.1.10.14 Containment draft Procedure Indications (DICOM-20150324) DYNAMIC
2.16.840.1.113883.10.20.22.2.39 Containment draft Medical (General) History Section (2.1) DYNAMIC
1.2.840.10008.9.23 Include draft General Section Entries (DICOM-20150324) DYNAMIC
Relationship Adaptation: template 1.2.840.10008.9.2 Clinical Information (2021‑06‑22 11:38:24)
ref
DICOM-
Example
Example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="1.2.840.10008.9.2"/>  <id root="1.2.840.10213.2.62.994044785528.114289542805"/>  <code code="55752-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical Information"/>  <title>Clinical Information</title>  <text>The patient was referred for evaluation of suspected pulmonary embolism.</text>  <!---see examples for other sections/entries -->
</section>
Item DT Card Conf Description Label
hl7:section
 		1 … 1 R (XeHdotsion)
hl7:templateId
 		II 1 … 1 M (XeHdotsion)
@root
 		uid 1 … 1 F 2.16.840.1.113883.2.51.10.61
hl7:id
 		II 1 … 1 R (XeHdotsion)
hl7:code
 		CD 1 … 1 R (XeHdotsion)
@code
 		CONF 0 … 1 F 55752-0
@codeSystem
 		0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <cda:code code="55752-0" codeSystem="2.16.840.1.113883.6.1"/>
hl7:title
 		ST 1 … 1 R (XeHdotsion)
hl7:text
 		SD.TEXT 1 … 1 M (XeHdotsion)
hl7:component
 		0 … 1 (XeHdotsion)
hl7:section
 		1 … 1 R Contains 1.2.840.10008.9.7 Request (DYNAMIC) (XeHdotsion)
hl7:component
 		0 … 1 (XeHdotsion)
hl7:section
 		1 … 1 R Contains 1.2.840.10008.9.1.10.14 Procedure Indications (DYNAMIC) (XeHdotsion)
hl7:component
 		0 … 1 (XeHdotsion)
hl7:section
 		1 … 1 R Contains 2.16.840.1.113883.10.20.22.2.39 Medical (General) History Section (DYNAMIC) (XeHdotsion)
Included 0 … 1 from 1.2.840.10008.9.23 General Section Entries (DYNAMIC)
hl7:templateId
 		II 0 … 1 (XeHdotsion)
hl7:author
 		0 … 1 (XeHdotsion)
  Example <hl7:author>
  <hl7:time value="20210806063409"/>  <hl7:assignedAuthor>
    <hl7:id root="1.2.3.999" extension="--example only--"/>    <hl7:assignedPerson>
      <hl7:name>name</hl7:name>    </hl7:assignedPerson>    <hl7:assignedAuthoringDevice>
      <hl7:manufacturerModelName>manufacturerModelName</hl7:manufacturerModelName>      <hl7:softwareName>softwareName</hl7:softwareName>    </hl7:assignedAuthoringDevice>    <hl7:representedOrganization>
      <hl7:name>name</hl7:name>    </hl7:representedOrganization>  </hl7:assignedAuthor></hl7:author>
hl7:time
 		TS 1 … 1 R (XeHdotsion)
hl7:assignedAuthor
 		1 … 1 R (XeHdotsion)
hl7:id
 		II 1 … * R (XeHdotsion)
hl7:assignedPerson
 		1 … 1 R (XeHdotsion)
hl7:name
 		PN 1 … 1 R (XeHdotsion)
hl7:assignedAuthoringDevice
 		1 … 1 R (XeHdotsion)
hl7:manufacturerModelName
 		ST 0 … 1 (XeHdotsion)
hl7:softwareName
 		ST 0 … 1 (XeHdotsion)
hl7:representedOrganization
 		0 … 1 (XeHdotsion)
hl7:name
 		ON 0 … 1 (XeHdotsion)
hl7:entry
 		0 … 1 (XeHdotsion)
hl7:observation
 		1 … 1 R Contains 2.16.840.1.113883.10.20.6.2.13 Code Observations (DYNAMIC) (XeHdotsion)
hl7:entry
 		0 … 1 (XeHdotsion)
hl7:observation
 		1 … 1 R Contains 2.16.840.1.113883.10.20.6.2.14 Quantity Measurement Observation (DYNAMIC) (XeHdotsion)
hl7:entry
 		0 … 1 (XeHdotsion)
hl7:observationMedia
 		1 … 1 R Contains 1.3.6.1.4.1.19376.1.4.1.4.7 Observation Media Entry (DYNAMIC) (XeHdotsion)
hl7:entry
 		0 … 1 (XeHdotsion)
hl7:observation
 		1 … 1 R Contains 1.2.840.10008.9.18 SOP Instance Observation (DYNAMIC) (XeHdotsion)
hl7:entry
 		0 … 1 (XeHdotsion)
hl7:regionOfInterest
 		NP (XeHdotsion)