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draft Template  Clinical Information

Id 1.2.840.10008.9.2
ref
DICOM-
 		Effective Date 2021‑06‑22 11:38:24
Status draft Draft Version Label DICOM-20150324
Name ClinicalInformation Display Name 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 1.2.840.10008.9.2
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 2 templates, Uses 5 templates
Used by as Name Version
2.16.840.1.113883.2.51.10.1.9.1 Containment cancelled XeH Imaging Report 2021‑06‑22 14:23:06
2.16.840.1.113883.2.51.10.45 Containment cancelled XeH Diagnostic Imaging Report2 (DICOM-20150324) 2021‑11‑08 15:59:54
Uses as Name Version
1.2.840.10008.9.19 Containment draft Text (DICOM-20150324) DYNAMIC
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
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 (Clidotsion)
hl7:templateId
 		II 1 … 1 M (Clidotsion)
@root
 		uid 1 … 1 F 1.2.840.10008.9.2
hl7:id
 		II 1 … 1 R (Clidotsion)
hl7:code
 		CD 1 … 1 R (Clidotsion)
@code
 		CONF 0 … 1 F 55752-0
@codeSystem
 		0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
  Example <hl7:code code="55752-0" codeSystem="2.16.840.1.113883.6.1"/>
hl7:title
 		ST 1 … 1 R (Clidotsion)
hl7:text
 		ED 1 … 1 R Contains 1.2.840.10008.9.19 Text (DYNAMIC) (Clidotsion)
hl7:component
 		0 … 1 (Clidotsion)
hl7:section
 		1 … 1 R Contains 1.2.840.10008.9.7 Request (DYNAMIC) (Clidotsion)
hl7:component
 		0 … 1 (Clidotsion)
hl7:section
 		1 … 1 R Contains 1.2.840.10008.9.1.10.14 Procedure Indications (DYNAMIC) (Clidotsion)
hl7:component
 		0 … 1 (Clidotsion)
hl7:section
 		1 … 1 R Contains 2.16.840.1.113883.10.20.22.2.39 Medical (General) History Section (DYNAMIC) (Clidotsion)
Included 0 … 1 from 1.2.840.10008.9.23 General Section Entries (DYNAMIC)
hl7:author
 		0 … 1 (Clidotsion)
  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 (Clidotsion)
hl7:assignedAuthor
 		1 … 1 R (Clidotsion)
hl7:id
 		II 1 … * R (Clidotsion)
hl7:assignedPerson
 		1 … 1 R (Clidotsion)
hl7:name
 		PN 1 … 1 R (Clidotsion)
hl7:assignedAuthoringDevice
 		1 … 1 R (Clidotsion)
hl7:manufacturerModelName
 		ST 0 … 1 (Clidotsion)
hl7:softwareName
 		ST 0 … 1 (Clidotsion)
hl7:representedOrganization
 		0 … 1 (Clidotsion)
hl7:name
 		ON 0 … 1 (Clidotsion)
hl7:entry
 		0 … 1 (Clidotsion)
hl7:observation
 		1 … 1 R Contains 2.16.840.1.113883.10.20.6.2.13 Code Observations (DYNAMIC) (Clidotsion)
hl7:entry
 		0 … 1 (Clidotsion)
hl7:observation
 		1 … 1 R Contains 2.16.840.1.113883.10.20.6.2.14 Quantity Measurement Observation (DYNAMIC) (Clidotsion)
hl7:entry
 		0 … 1 (Clidotsion)
hl7:observationMedia
 		1 … 1 R Contains 1.3.6.1.4.1.19376.1.4.1.4.7 Observation Media Entry (DYNAMIC) (Clidotsion)
hl7:entry
 		0 … 1 (Clidotsion)
hl7:observation
 		1 … 1 R Contains 1.2.840.10008.9.18 SOP Instance Observation (DYNAMIC) (Clidotsion)
hl7:entry
 		0 … 1 (Clidotsion)
hl7:regionOfInterest
 		NP (Clidotsion)