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 Template  Vital Signs Summary CDA document

Template 2.16.840.1.113883.3.1937.99.60.5.10.1 - VitalSignsCDAdocument
Id 2.16.840.1.113883.3.1937.99.60.5.10.1
Classification CDA document level template
Relationship Specialization: template 2.16.840.1.113883.10.12.1 (2005‑09‑07)
Context Pathname /
Version valid from 2014‑07‑08 status Under develeopment
Open/Closed Open (other than defined elements are allowed)
Description A minimal CDA Release 2 document, that contains only a few attributes and relationships for the ClinicalDocument class:
  • typeId: fixed
  • id: unique id of the document instance
  • code: type of document
  • effectiveTime: creation date of the document
  • confidentialityCode: confidentiality level indication for this document
  • recordTarget: the record target (e.g. patient)
  • author: author of this document
  • custodian: custodian for this document
  • component: contains (in this case) structured body
Used by / Uses
Used by / Uses 9 templates
Example
<ClinicalDocument>
  <!-- CDA Header -->
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
  <templateId root="2.16.840.1.113883.3.1937.99.60.5.10.1"/>
  <id extension="38457384973598" root="2.16.840.1.113883.3.1937.99.3.2.56754657.1"/>
  <code code="51848-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Assessment note"/>
  <effectiveTime value="20140708123456"/>
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
  <recordTarget>
    <!-- .. -->
  </recordTarget>
  <author>
    <!-- .. -->
  </author>
  <custodian>
    <!-- .. -->
  </custodian>
  <!-- CDA Body -->
  <component>
    <structuredBody>
      <component>
        <!-- .. -->
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>
Item DT Card Conf Desc Label
hl7:ClinicalDocument
(VitalSignsCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900001 CDA typeId (DYNAMIC)
treetree hl7:typeId
II 1 .. 1 CDAtypeId
treeblank treetree @extension
1 .. 1 F POCD_HD000040
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.1.3
treetree hl7:templateId
II 1 .. 1 M CDA document template id for this kind of document (VitalSignsCDAdocument)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.3.1937.99.60.5.10.1
Example
<templateId root="2.16.840.1.113883.3.1937.99.60.5.10.1"/>
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900002 CDA id (DYNAMIC)
treetree hl7:id
II 1 .. 1 (VitalSignsCDAdocument)
treetree hl7:code
CE 1 .. 1 M (VitalSignsCDAdocument)
treeblank treetree @code
1 .. 1 F 51848-0
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900003 CDA title (DYNAMIC) 0 .. 1
Example
<title>Assessment Note as of 8 July 2014</title>
treetree hl7:title
ST 0 .. 1 (VitalSignsCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900004 CDA effectiveTime (DYNAMIC)
treetree hl7:effectiveTime
TS.DATETIME.MIN 1 .. 1 (VitalSignsCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900005 CDA confidentialityCode (DYNAMIC)
treetree hl7:confidentialityCode
CE 1 .. 1 (VitalSignsCDAdocument)
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 Basic Confidentiality Kind (HL7) (DYNAMIC)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.2001 CDA recordTarget (DYNAMIC)
treetree hl7:recordTarget
(VitalSignsCDAdocument)
treeblank treetree @typeCode
0 .. 1 F RCT
treeblank treetree @contextControlCode
0 .. 1 F OP
target Associated with concepts:
demo5-dataelement-10 Person
treeblank treetree hl7:patientRole
1 .. 1 (VitalSignsCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F PAT
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900207 Burgerservicenummer (DYNAMIC) 1 .. 1 Required
treeblank treeblank treetree hl7:id
II.NL.BSN 1 .. 1 R (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.2.4.6.3
treeblank treeblank treeblank treetree @extension
1 .. 1  
  National Patient Identifier (Burgerservicenummer)
target Associated with concepts:
demo5-dataelement-110 National Patient Identifier
treeblank treeblank treetree hl7:patient
1 .. 1 R (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree @classCode
0 .. 1 F PSN
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
Example
<patient classCode="PSN" determinerCode="INSTANCE">
  <name>
    <!-- ... -->
  </name>
  <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1"/>
  <birthTime value="19620219"/>
</patient>
treeblank treeblank treeblank treetree hl7:name
PN 1 .. * R (VitalSignsCDAdocument)
target Associated with concepts:
demo5-dataelement-100 Name
treeblank treeblank treeblank treetree hl7:administrativeGenderCode
CE 1 .. 1 R (VitalSignsCDAdocument)
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMIC)
target Associated with concepts:
demo5-dataelement-130 Gender
treeblank treeblank treeblank treetree hl7:birthTime
TS 1 .. 1 R (VitalSignsCDAdocument)
target Associated with concepts:
demo5-dataelement-120 Date of birth
Included from 2.16.840.1.113883.3.1937.99.60.5.10.2002 CDA author (DYNAMIC)
treetree hl7:author
1 .. * (VitalSignsCDAdocument)
treeblank treetree @typeCode
0 .. 1 F AUT
treeblank treetree hl7:time
TS.DATE.MIN 1 .. 1 M (VitalSignsCDAdocument)
treeblank treetree hl7:assignedAuthor
1 .. 1 M (VitalSignsCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:id
II 1 .. 1 R (VitalSignsCDAdocument)
treeblank treeblank treetree hl7:assignedPerson
0 .. 1 (VitalSignsCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900200 CDA Person Elements (DYNAMIC)
treeblank treeblank treeblank treetree @classCode
0 .. 1 F PSN
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:name
PN 1 .. 1 (VitalSignsCDAdocument)
treeblank treeblank treeblank treeblank treetree hl7:family
ST 1 .. 1 M (VitalSignsCDAdocument)
treeblank treeblank treeblank treeblank treetree hl7:given
ST 1 .. 1 M (VitalSignsCDAdocument)
treeblank treeblank treetree hl7:representedOrganization
0 .. 1 (VitalSignsCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900201 CDA Organization Elements (DYNAMIC)
treeblank treeblank treeblank treetree @classCode
0 .. 1 F ORG
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:id
II 0 .. * (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree hl7:name
ON 1 .. 1 (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree hl7:telecom
TEL 0 .. * (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree hl7:addr
AD 0 .. 1 (VitalSignsCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.2003 CDA custodian (DYNAMIC)
treetree hl7:custodian
1 .. 1 (VitalSignsCDAdocument)
treeblank treetree @typeCode
0 .. 1 F CST
treeblank treetree hl7:assignedCustodian
1 .. 1 M (VitalSignsCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:representedCustodianOrganization
0 .. 1 (VitalSignsCDAdocument)
Included from 2.16.840.1.113883.3.1937.99.60.5.10.900201 CDA Organization Elements (DYNAMIC)
treeblank treeblank treeblank treetree @classCode
0 .. 1 F ORG
treeblank treeblank treeblank treetree @determinerCode
0 .. 1 F INSTANCE
treeblank treeblank treeblank treetree hl7:id
II 0 .. * (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree hl7:name
ON 1 .. 1 (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree hl7:telecom
TEL 0 .. * (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree hl7:addr
AD 0 .. 1 (VitalSignsCDAdocument)
treetree hl7:component
(VitalSignsCDAdocument)
treeblank treetree @typeCode
0 .. 1 F COMP
treeblank treetree @contextConductionInd
0 .. 1 F true
treeblank treetree hl7:structuredBody
(VitalSignsCDAdocument)
treeblank treeblank treetree @classCode
0 .. 1 F DOCBODY
treeblank treeblank treetree @moodCode
0 .. 1 F EVN
treeblank treeblank treetree hl7:component
where
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.1937.99.60.5.10.3001']]]
1 .. 1 M (VitalSignsCDAdocument)
treeblank treeblank treeblank treetree @typeCode
0 .. 1 F COMP
treeblank treeblank treeblank treetree @contextConductionInd
0 .. 1 F true
Contains 2.16.840.1.113883.3.1937.99.60.5.10.3001 Vital Signs Section (2014‑07‑08) with overridden cardinality 1 .. 1 Mandatory