Template 2.16.840.1.113883.2.4.3.36.10.10
Resultaatdocument MDL bevolkingsonderzoek darmkanker
2012‑07‑04
Template
2.16.840.1.113883.2.4.3.36.10.10 - nspbcmdl
Id
2.16.840.1.113883.2.4.3.36.10.10
Classificatie
cdadocumentlevel
Context
Padnaam //
Versie
geldig vanaf 2012‑07‑04 status draft
Omschrijving
Template voor CDA document resultaten bevolkingsonderzoek darmkanker voor screeningsorganisatie (maag-, darm-, levercentrum)
Item
DT
Card
Conf
Desc
Label
hl7:ClinicalDocument
(nspbcmdl)
Ingevoegd van
CDArealmCode
hl7:realmCode
CS
1..1
M
CDArealmCode
@
code
1..1
F
NL
Ingevoegd van
CDAtypeId
hl7:typeId
II
1..1
M
CDAtypeId
@
extension
1..1
F
POCD_HD000040
@
root
1..1
F
2.16.840.1.113883.1.3
hl7:templateId
II
1..1
M
Generic CDA document template for the National Screening Programme RIVM
(nspbcmdl)
@
root
1..1
F
2.16.840.1.113883.2.4.3.36.10.1
Voorbeeld
<
templateId
root
="
2.16.840.1.113883.2.4.3.36.10.1
"
/
>
hl7:templateId
II
1..1
M
CDA document template MDL
(nspbcmdl)
@
root
1..1
F
2.16.840.1.113883.2.4.3.36.10.10
Voorbeeld
<
templateId
root
="
2.16.840.1.113883.2.4.3.36.10.10
"
/
>
Ingevoegd van
CDAid
hl7:id
II
1..1
M
(nspbcmdl)
hl7:code
CE
1..1
M
(nspbcmdl)
@
code
1..1
F
18746-8
@
codeSystem
1..1
F
2.16.840.1.113883.6.1 (LOINC)
Voorbeeld
<!-- document typering -->
<
code
code
="
18746-8
"
displayName
="
Colonoscopy study
"
codeSystem
="
2.16.840.1.113883.6.1
"
codeSystemName
="
LOINC
"
/
>
Ingevoegd van
CDAtitle
Voorbeeld
<
title
>
Colonoscopie verslag dd 21 mei 2012
</
title
>
hl7:title
ST
0..1
O
(nspbcmdl)
Ingevoegd van
CDAeffectiveTime
hl7:effectiveTime
TS.DATETIME.MIN
1..1
M
(nspbcmdl)
Ingevoegd van
CDAconfidentialityCode
hl7:confidentialityCode
CE
1..1
M
(nspbcmdl)
CONF
De waarde van @code moet komen uit waardenlijst
BasicConfidentialityKind
Ingevoegd van
CDAlanguageCode
hl7:languageCode
CS.LANG
1..1
M
(nspbcmdl)
Ingevoegd van
CDAsetIdversionNumber
hl7:setId
II
0..1
O
(nspbcmdl)
hl7:versionNumber
INT.NONNEG
0..1
O
(nspbcmdl)
CONF
@value low boundary is 1
Schematron assert
Role
error
Test
(../hl7:setId and ../hl7:versionNumber) or not (../hl7:setId or ../hl7:versionNumber)
Melding
CDAsetIdversionNumber: Clinical Document setId and versionNumber SHALL be both present or both absent
Ingevoegd van
CDArecordTarget
hl7:recordTarget
(nspbcmdl)
@
typeCode
1..1
F
RCT
Id als doel
2.16.840.1.113883.2.4.3.36.77.9.900808.1
Target of concept id(s):
rivm-dataelement41-
105000
Burger
hl7:patientRole
1..1
M
(nspbcmdl)
@
classCode
1..1
F
PAT
Ingevoegd van
BurgerServiceNummer
hl7:id
II.NL.BSN
Civil Service Number - Burger Service Nummer
(nspbcmdl)
@
root
1..1
F
2.16.840.1.113883.2.4.6.3
Id als doel
2.16.840.1.113883.2.4.3.36.77.9.900014.1
Target of concept id(s):
rivm-dataelement41-
105010
Burger Service Nummer
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
Ingevoegd van
CDAauthor
hl7:author
1..*
M
(nspbcmdl)
@
typeCode
1..1
F
AUT
hl7:templateId
II
1..1
(nspbcmdl)
@
root
1..1
F
2.16.840.1.113883.2.4.3.36.10.100
hl7:time
TS.DATE.MIN
1..1
M
(nspbcmdl)
hl7:assignedAuthor
1..1
M
(nspbcmdl)
@
classCode
1..1
F
ASSIGNED
Ingevoegd van
CDAassignedEntityIdentification
hl7:id
II
0..1
O
UZI
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.1
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:code
CE
0..1
O
(nspbcmdl)
CONF
De waarde van @code moet komen uit waardenlijst
vs_typerol
flexibiliteit dynamic
hl7:assignedPerson
0..1
O
(nspbcmdl)
@
classCode
1..1
F
PSN
@
determinerCode
1..1
F
INSTANCE
hl7:name
PN
1..1
M
(nspbcmdl)
Ingevoegd van
CDArepresentedOrganization
hl7:representedOrganization
0..1
O
(nspbcmdl)
@
classCode
1..1
F
ORG
@
determinerCode
1..1
F
INSTANCE
hl7:id
II
0..1
O
URA
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.3
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:name
ON
1..1
M
(nspbcmdl)
hl7:addr
AD
1..1
M
(nspbcmdl)
hl7:telecom
TEL
0..*
O
(nspbcmdl)
Ingevoegd van
CDAcustodian
hl7:custodian
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
CST
hl7:assignedCustodian
1..1
M
(nspbcmdl)
@
classCode
1..1
F
ASSIGNED
Ingevoegd van
CDArepresentedOrganization
hl7:representedOrganization
0..1
O
(nspbcmdl)
@
classCode
1..1
F
ORG
@
determinerCode
1..1
F
INSTANCE
hl7:id
II
0..1
O
URA
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.3
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:name
ON
1..1
M
(nspbcmdl)
hl7:addr
AD
1..1
M
(nspbcmdl)
hl7:telecom
TEL
0..*
O
(nspbcmdl)
Ingevoegd van
CDAinformationRecipient
hl7:informationRecipient
0..*
O
(nspbcmdl)
@
typeCode
1..1
@typeCode moet één zijn van:
PRCP
TRC
hl7:intendedRecipient
1..1
M
(nspbcmdl)
@
classCode
1..1
F
ASSIGNED
hl7:informationRecipient
0..1
O
(nspbcmdl)
@
classCode
1..1
F
PSN
@
determinerCode
1..1
F
INSTANCE
hl7:name
PN
0..1
O
(nspbcmdl)
Ingevoegd van
CDArepresentedOrganization
hl7:representedOrganization
0..1
O
(nspbcmdl)
@
classCode
1..1
F
ORG
@
determinerCode
1..1
F
INSTANCE
hl7:id
II
0..1
O
URA
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.3
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:name
ON
1..1
M
(nspbcmdl)
hl7:addr
AD
1..1
M
(nspbcmdl)
hl7:telecom
TEL
0..*
O
(nspbcmdl)
Ingevoegd van
CDAauthenticator
hl7:authenticator
0..*
O
(nspbcmdl)
@
typeCode
1..1
F
AUTHEN
Ingevoegd van
CDlegalAuthenticator
hl7:legalAuthenticator
0..1
O
(nspbcmdl)
@
typeCode
1..1
F
LA
hl7:time
TS.DATE.MIN
1..1
M
(nspbcmdl)
hl7:signatureCode
CS
1..1
M
(nspbcmdl)
@
code
1..1
F
S
hl7:assignedEntity
1..1
M
(nspbcmdl)
@
classCode
1..1
F
ASSIGNED
Ingevoegd van
CDAassignedEntityIdentification
hl7:id
II
0..1
O
UZI
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.1
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:code
CE
0..1
O
(nspbcmdl)
CONF
De waarde van @code moet komen uit waardenlijst
vs_typerol
flexibiliteit dynamic
hl7:assignedPerson
0..1
O
(nspbcmdl)
@
classCode
1..1
F
PSN
@
determinerCode
1..1
F
INSTANCE
hl7:name
PN
1..1
M
(nspbcmdl)
Ingevoegd van
CDArepresentedOrganization
hl7:representedOrganization
0..1
O
(nspbcmdl)
@
classCode
1..1
F
ORG
@
determinerCode
1..1
F
INSTANCE
hl7:id
II
0..1
O
URA
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.3
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:name
ON
1..1
M
(nspbcmdl)
hl7:addr
AD
1..1
M
(nspbcmdl)
hl7:telecom
TEL
0..*
O
(nspbcmdl)
Ingevoegd van
CDArelatedDocument
hl7:relatedDocument
0..1
O
(nspbcmdl)
@
typeCode
1..1
F
RPLC
Ingevoegd van
CDAdocumentationOf
hl7:documentationOf
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
DOC
hl7:serviceEvent
1..1
M
(nspbcmdl)
@
classCode
1..1
F
OBS
@
moodCode
1..1
F
EVN
hl7:id
II
1..1
(nspbcmdl)
hl7:code
CE
1..1
M
(nspbcmdl)
@
code
1..1
F
18746-8
@
codeSystem
1..1
F
2.16.840.1.113883.6.1 (LOINC)
lab:statusCode
CS
1..1
M
(nspbcmdl)
@
code
1..1
F
completed
hl7:effectiveTime
IVL_TS
0..1
O
(nspbcmdl)
Ingevoegd van
StartServiceDate
hl7:low
TS
1..1
M
(nspbcmdl)
Id als doel
2.16.840.1.113883.2.4.3.36.77.9.900005.1
Target of concept id(s):
rivm-dataelement41-
125030
Aanvang verrichting
Ingevoegd van
EndServiceDate
hl7:high
TS
1..1
M
(nspbcmdl)
Id als doel
2.16.840.1.113883.2.4.3.36.77.9.900035.1
Target of concept id(s):
rivm-dataelement41-
125050
Einde verrichting
hl7:performer
1..1
(nspbcmdl)
@
typeCode
1..1
F
PRF
hl7:assignedEntity
1..1
(nspbcmdl)
@
classCode
1..1
F
ASSIGNED
Ingevoegd van
CDAassignedEntityIdentification
hl7:id
II
0..1
O
UZI
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.1
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:code
CE
1..1
(nspbcmdl)
CONF
De waarde van @code moet komen uit waardenlijst
vs_typerol
flexibiliteit dynamic
hl7:addr
AD
0..*
O
(nspbcmdl)
hl7:telecom
TEL
0..*
O
(nspbcmdl)
hl7:assignedPerson
1..1
(nspbcmdl)
@
classCode
1..1
F
PSN
@
determinerCode
1..1
F
INSTANCE
hl7:name
PN
1..*
(nspbcmdl)
Ingevoegd van
CDArepresentedOrganization
hl7:representedOrganization
0..1
O
(nspbcmdl)
@
classCode
1..1
F
ORG
@
determinerCode
1..1
F
INSTANCE
hl7:id
II
0..1
O
URA
(nspbcmdl)
@
root
1..1
F
2.16.528.1.1007.3.3
hl7:id
II
0..*
O
Other IDs
(nspbcmdl)
hl7:name
ON
1..1
M
(nspbcmdl)
hl7:addr
AD
1..1
M
(nspbcmdl)
hl7:telecom
TEL
0..*
O
(nspbcmdl)
hl7:component
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Voorbeeld
<!-- now for the study results: CDA body -->
<
component
typeCode
="
COMP
"
contextConductionInd
="
true
"
>
<!-- ... -->
</
component
>
hl7:structuredBody
(nspbcmdl)
@
classCode
1..1
F
DOCBODY
@
moodCode
1..1
F
EVN
Voorbeeld
<
structuredBody
classCode
="
DOCBODY
"
moodCode
="
EVN
"
>
<!-- ... -->
</
structuredBody
>
hl7:component
waar
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.2.4.3.36.10.201']]]
0..1
O
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Bevat
geërfde templateregels
SalutationSection
met overschreven kardinaliteit 0 .. 1
hl7:component
waar
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.2.4.3.36.10.202']]]
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Bevat
geërfde templateregels
ProcedureIndicationsSection
met overschreven kardinaliteit 1 .. 1 mandatory
hl7:component
waar
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.2.4.3.36.10.203']]]
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Bevat
geërfde templateregels
ProcedureDescriptionSection
met overschreven kardinaliteit 1 .. 1 mandatory
hl7:component
waar
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.2.4.3.36.10.204']]]
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Bevat
geërfde templateregels
ProcedureFindingsSection
met overschreven kardinaliteit 1 .. 1 mandatory
hl7:component
waar
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.2.4.3.36.10.205']]]
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Bevat
geërfde templateregels
AssessmentSection
met overschreven kardinaliteit 1 .. 1 mandatory
hl7:component
waar
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.2.4.3.36.10.207']]]
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Bevat
geërfde templateregels
PlanOfCareSection
met overschreven kardinaliteit 1 .. 1 mandatory
hl7:component
waar
[hl7:section [hl7:templateId [@root='2.16.840.1.113883.2.4.3.36.10.208']]]
1..1
M
(nspbcmdl)
@
typeCode
1..1
F
COMP
@
contextConductionInd
1..1
F
true
Bevat
geërfde templateregels
ConclusionsSection
met overschreven kardinaliteit 1 .. 1 mandatory
Template 2.16.840.1.113883.2.4.3.36.10.10 Resultaatdocument MDL bevolkingsonderzoek darmkanker Template 2.16.840.1.113883.2.4.3.36.10.10 Resultaatdocument MDL bevolkingsonderzoek darmkanker
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