| Template |
2.16.840.1.113883.2.4.3.11.60.66.10.301 - kezo-ClinicalInformation |
| Id |
2.16.840.1.113883.2.4.3.11.60.66.10.301 |
| Classificatie |
CDA section level template |
| Relatie |
Specialisatie: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
|
| Context |
Parent nodes van template element met id 2.16.840.1.113883.2.4.3.11.60.66.10.301 |
| Versie |
geldig vanaf 2014‑06‑27 status In ontwikkeling |
| Open/gesloten |
Open (ook andere dan gedefinieerde elementen zijn toegestaan) |
| Omschrijving |
 A section containing clinical details about the case such as presenting signs and
symptoms, onset date of symptoms,
the specific diagnosis/condition names (e.g Ulceroglandular tularemia), who made the
diagnosis, their contact information,
when the diagnosis was made etc., past clinical hx, the overall condition of the patient,
etc. |
| Voorbeeld |
<section>
<templateId root="2.16.840.1.113883.2.4.3.11.60.66.10.301"/>
<code code="55752-0" codeSystem="2.16.840.1.113883.6.1" displayName="Clinical information"/>
<title>Informatie verwijzing</title>
<text>Patiënt met diabetes sinds mei 1991, goed ingesteld. Lichaamsgewicht 101 kg, HbA1c
8%. Hij wordt doorverwezen ivm kleurenzienstoornissen en refractie stoornissen.</text> </section> |
| Item |
DT |
Card |
Conf |
Omschrijving |
Label |
|
|
|
1 .. 1 |
M |
|
(kezo-ClinicalInformation) |
 |
hl7:templateId
|
|
|
1 .. 1 |
M |
|
(kezo-ClinicalInformation) |
 |
|
@root
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.2.4.3.11.60.66.10.301 |
|
hl7:code
|
|
CE |
1 .. 1 |
M |
|
(kezo-ClinicalInformation) |
|
|
@code
|
|
|
1 .. 1 |
F |
55752-0 |
|
|
@codeSystem
|
|
|
1 .. 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
|
|
@displayName
|
|
|
1 .. 1 |
F |
Clinical information |
|
hl7:title
|
|
ST |
0 .. 1 |
|
|
(kezo-ClinicalInformation) |
|
hl7:text
|
|
ED |
1 .. 1 |
M |
|
(kezo-ClinicalInformation) |
|
Template KEZO Clinical Information Section