hl7:ClinicalDocument
|
|
|
|
|
(nsp014) |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900800 CDA realmCode (DYNAMISCH)
|
hl7:realmCode
|
CS |
1 … 1 |
M |
|
CDArCode |
@code
|
CONF |
1 … 1 |
F |
NL |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900801 CDA typeId (DYNAMISCH)
|
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 |
CDA document template PA-lab, this shall be the first template id in ClinicalDocument |
(nsp014) |
@root
|
|
1 … 1 |
F |
2.16.840.1.113883.2.4.3.36.10.21 |
|
Voorbeeld |
<templateId root="2.16.840.1.113883.2.4.3.36.10.21"/> |
hl7:templateId
|
II |
1 … 1 |
M |
Generic CDA document template for the National Screening Programme RIVM |
(nsp014) |
@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 |
0 … 1 |
|
conformance to a generic ASPR (IHE Anatomic Pathology Technical Framework) content
module
|
(nsp014) |
@root
|
|
1 … 1 |
F |
1.3.6.1.4.1.19376.1.8.1.1.1 |
|
Voorbeeld |
<templateId root="1.3.6.1.4.1.19376.1.8.1.1.1"/> |
hl7:templateId
|
II |
0 … 1 |
|
conformance to a ASPR colon content module |
(nsp014) |
@root
|
|
1 … 1 |
F |
1.3.6.1.4.1.19376.1.8.1.1.2.2 |
|
Voorbeeld |
<templateId root="1.3.6.1.4.1.19376.1.8.1.1.2.2"/> |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900802 CDA id (DYNAMISCH) Pathologieverslagen worden geïdentificeerd met T-nummers of pa-nummers. Een verslag
wordt normaal aangeduid met een pa-nummer: Xjj-nnnnn (b.v. T12-60123). Een specifieke
versie kan worden aangegeven met de versie-aanduiding (letter) daar achter (b.v. T12-60123A).
Maar de versie wordt tot dusver alleen intern in het lab gebruikt (en heel recent
tussen laboratoria onderling waar ook CDA consult uitslagen verstuurd worden), naar
buiten toe (MDL) gaat alleen het pa-nummer. Deze nummers worden opgenomen in de CDA PA verslagen,
zonder streepje:
- pa-nummer (met volgletter): staat in ClinicalDocument.id (b.v. T1260123A)
|
hl7:id
|
II |
1 … 1 |
M |
|
(nsp014) |
hl7:code
|
CE |
1 … 1 |
M |
|
(nsp014) |
@code
|
CONF |
1 … 1 |
F |
11526-1 |
@codeSystem
|
1 … 1 |
F |
2.16.840.1.113883.6.1 (LOINC) |
|
Voorbeeld |
<code code="11526-1" displayName="Pathology study" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> |
Inclusie |
0 … 1 |
|
van 2.16.840.1.113883.2.4.3.36.10.900803 CDA title (DYNAMISCH)
|
|
Voorbeeld |
<title>Pathologieverslag dd 22 mei 2012</title> |
hl7:title
|
ST |
0 … 1 |
|
|
(nsp014) |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900804 CDA effectiveTime (DYNAMISCH)
|
hl7:effectiveTime
|
TS.DATETIME.MIN |
1 … 1 |
M |
|
(nsp014) |
|
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900805 CDA confidentialityCode (DYNAMISCH)
|
hl7:confidentialityCode
|
CE |
1 … 1 |
M |
|
(nsp014) |
|
CONF |
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900806 CDA languageCode (DYNAMISCH)
|
hl7:languageCode
|
CS.LANG |
1 … 1 |
M |
|
(nsp014) |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900807 CDA setId and versionNumber (DYNAMISCH) setId is tevens het T-nummer laboratorium. Pathologieverslagen worden geïdentificeerd
met T-nummers of pa-nummers. Een verslag wordt normaal aangeduid met een pa-nummer:
Xjj-nnnnn (b.v. T12-60123). Een specifieke versie kan worden aangegeven met de versie-aanduiding
(letter) daar achter (b.v. T12-60123A). Maar de versie wordt tot dusver alleen intern in het lab gebruikt (en heel recent
tussen laboratoria onderling waar ook CDA consult uitslagen verstuurd worden), naar
buiten toe (MDL) gaat alleen het pa-nummer. Deze nummers worden opgenomen
in de CDA PA verslagen, zonder streepje:
- pa-nummer (zonder volgletter): staat in ClinicalDocument.setId (b.v. T1260123)
|
|
Voorbeeld |
<setId extension="T1260123" root="2.16.840.1.113883.2.4.99.3.20"/><versionNumber value="1"/> |
hl7:setId
|
II |
1 … 1 |
M |
|
(nsp014) |
@root
|
|
1 … 1 |
R |
|
@extension
|
|
1 … 1 |
R |
|
|
|
hl7:versionNumber
|
INT.NONNEG |
1 … 1 |
M |
|
(nsp014) |
|
CONF |
minInclude ondergrens is "1" |
|
Inclusie |
1 … 1 |
M |
van 2.16.840.1.113883.2.4.3.36.10.900831 CDA recordTarget PA (DYNAMISCH)
|
hl7:recordTarget
|
|
1 … 1 |
M |
|
(nsp014) |
|
|
@typeCode
|
|
1 … 1 |
F |
RCT |
hl7:patientRole
|
|
1 … 1 |
M |
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
PAT |
Inclusie |
1 … 1 |
M |
van 2.16.840.1.113883.2.4.3.36.10.900014 Burger Service Nummer (DYNAMISCH)
|
hl7:id
|
II.NL.BSN |
1 … 1 |
M |
Civil Service Number - Burger Service Nummer |
(nsp014) |
|
|
|
waar [@root='2.16.840.1.113883.2.4.6.3'] |
|
|
|
|
@root
|
|
1 … 1 |
F |
2.16.840.1.113883.2.4.6.3 |
@extension
|
|
1 … 1 |
R |
|
Inclusie |
1 … 1 |
M |
van 2.16.840.1.113883.2.4.3.36.10.100 CDA author (DYNAMISCH)
|
hl7:author
|
|
1 … 1 |
M |
|
(nsp014) |
|
|
@typeCode
|
|
1 … 1 |
F |
AUT |
hl7:templateId
|
II |
1 … 1 |
|
|
(nsp014) |
@root
|
|
1 … 1 |
F |
2.16.840.1.113883.2.4.3.36.10.100 |
hl7:time
|
TS.DATE.MIN |
1 … 1 |
M |
|
(nsp014) |
hl7:assignedAuthor
|
|
1 … 1 |
M |
|
(nsp014) |
|
|
@classCode
|
|
1 … 1 |
F |
ASSIGNED |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900829 CDA Assigned Entity Identification (DYNAMISCH)
|
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.1']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
UZI |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.1 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.20.1" extension="KG56475673"/> |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.45.768.34212.34.323"/> |
hl7:code
|
CE |
0 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
hl7:assignedPerson
|
|
0 … 1 |
|
|
(nsp014) |
|
|
@classCode
|
|
1 … 1 |
F |
PSN |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … 1 |
M |
|
(nsp014) |
hl7:representedOrganization
|
|
1 … 1 |
|
|
(nsp014) |
|
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900809 CDA represented organization (DYNAMISCH)
|
@classCode
|
|
1 … 1 |
F |
ORG |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.3']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
URA |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.3 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.1234"/> |
hl7:name
|
ON |
1 … 1 |
M |
|
(nsp014) |
|
|
hl7:addr
|
AD |
0 … 1 |
|
|
(nsp014) |
|
|
hl7:telecom
|
TEL |
0 … * |
|
|
(nsp014) |
lab:code
|
CE |
0 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
Inclusie |
1 … 1 |
M |
van 2.16.840.1.113883.2.4.3.36.10.900810 CDA custodian (DYNAMISCH)
|
hl7:custodian
|
|
1 … 1 |
M |
|
(nsp014) |
@typeCode
|
|
1 … 1 |
F |
CST |
hl7:assignedCustodian
|
|
1 … 1 |
M |
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
ASSIGNED |
hl7:representedCustodianOrganization
|
|
0 … 1 |
|
|
(nsp014) |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900809 CDA represented organization (DYNAMISCH)
|
@classCode
|
|
1 … 1 |
F |
ORG |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.3']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
URA |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.3 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.1234"/> |
hl7:name
|
ON |
1 … 1 |
M |
|
(nsp014) |
|
|
hl7:addr
|
AD |
0 … 1 |
|
|
(nsp014) |
|
|
hl7:telecom
|
TEL |
0 … * |
|
|
(nsp014) |
lab:code
|
CE |
0 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
Inclusie |
0 … * |
|
van 2.16.840.1.113883.2.4.3.36.10.900811 CDA informationRecipient (DYNAMISCH)
|
hl7:informationRecipient
|
|
0 … * |
|
|
(nsp014) |
@typeCode
|
|
1 … 1 |
R |
|
|
CONF |
@typeCode moet "PRCP" zijn |
of |
@typeCode moet "TRC" zijn |
|
hl7:intendedRecipient
|
|
1 … 1 |
M |
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
ASSIGNED |
hl7:id
|
II |
0 … * |
|
|
(nsp014) |
hl7:informationRecipient
|
|
0 … 1 |
|
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
PSN |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
0 … 1 |
|
|
(nsp014) |
hl7:representedOrganization
|
|
0 … 1 |
|
|
(nsp014) |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900809 CDA represented organization (DYNAMISCH)
|
@classCode
|
|
1 … 1 |
F |
ORG |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.3']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
URA |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.3 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.1234"/> |
hl7:name
|
ON |
1 … 1 |
M |
|
(nsp014) |
|
|
hl7:addr
|
AD |
0 … 1 |
|
|
(nsp014) |
|
|
hl7:telecom
|
TEL |
0 … * |
|
|
(nsp014) |
lab:code
|
CE |
0 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
Inclusie |
0 … * |
|
van 2.16.840.1.113883.2.4.3.36.10.900812 CDA authenticator (DYNAMISCH)
|
hl7:authenticator
|
|
0 … * |
|
|
(nsp014) |
@typeCode
|
|
1 … 1 |
F |
AUTHEN |
Inclusie |
0 … 1 |
|
van 2.16.840.1.113883.2.4.3.36.10.900813 CDA legalAuthenticator (DYNAMISCH)
|
hl7:legalAuthenticator
|
|
0 … 1 |
|
|
(nsp014) |
|
|
@typeCode
|
|
1 … 1 |
F |
LA |
hl7:time
|
TS.DATE.MIN |
1 … 1 |
R |
|
(nsp014) |
|
|
hl7:signatureCode
|
CS |
1 … 1 |
M |
|
(nsp014) |
@code
|
CONF |
1 … 1 |
F |
S |
hl7:assignedEntity
|
|
1 … 1 |
M |
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
ASSIGNED |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900829 CDA Assigned Entity Identification (DYNAMISCH)
|
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.1']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
UZI |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.1 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.20.1" extension="KG56475673"/> |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.45.768.34212.34.323"/> |
hl7:code
|
CE |
0 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
hl7:assignedPerson
|
|
0 … 1 |
|
|
(nsp014) |
|
|
@classCode
|
|
1 … 1 |
F |
PSN |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … 1 |
M |
|
(nsp014) |
hl7:representedOrganization
|
|
0 … 1 |
|
|
(nsp014) |
|
|
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900809 CDA represented organization (DYNAMISCH)
|
@classCode
|
|
1 … 1 |
F |
ORG |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.3']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
URA |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.3 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.1234"/> |
hl7:name
|
ON |
1 … 1 |
M |
|
(nsp014) |
|
|
hl7:addr
|
AD |
0 … 1 |
|
|
(nsp014) |
|
|
hl7:telecom
|
TEL |
0 … * |
|
|
(nsp014) |
lab:code
|
CE |
0 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
Inclusie |
0 … * |
|
van 2.16.840.1.113883.2.4.3.36.10.900814 CDA relatedDocument (DYNAMISCH)
|
hl7:relatedDocument
|
|
0 … * |
|
|
(nsp014) |
@typeCode
|
|
1 … 1 |
F |
RPLC |
Inclusie |
0 … * |
|
van 2.16.840.1.113883.2.4.3.36.10.900816 CDA documentationOf (PA-lab) (DYNAMISCH)
|
hl7:documentationOf
|
|
0 … * |
M |
|
Waarschuwing: Als isMandatory=true, dan moet minimumMultiplicity groter dan 0 zijn. |
|
(nsp014) |
@typeCode
|
|
1 … 1 |
F |
DOC |
hl7:serviceEvent
|
|
1 … 1 |
M |
|
(nsp014) |
|
|
@classCode
|
|
1 … 1 |
F |
OBS |
@moodCode
|
|
1 … 1 |
F |
EVN |
hl7:id
|
II |
1 … 1 |
|
|
(nsp014) |
hl7:code
|
CE |
1 … 1 |
M |
|
(nsp014) |
|
CONF |
|
lab:statusCode
|
CS |
1 … 1 |
M |
|
(nsp014) |
@code
|
CONF |
1 … 1 |
F |
completed |
hl7:effectiveTime
|
IVL_TS |
0 … 1 |
|
|
(nsp014) |
Inclusie |
1 … 1 |
|
van 2.16.840.1.113883.2.4.3.36.10.900005 Aanvang verrichting (DYNAMISCH)
|
hl7:low
|
TS |
1 … 1 |
|
|
(nsp014) |
|
|
Inclusie |
1 … 1 |
M |
van 2.16.840.1.113883.2.4.3.36.10.900035 Einde verrichting (DYNAMISCH)
|
hl7:high
|
TS |
1 … 1 |
M |
|
(nsp014) |
|
|
hl7:performer
|
|
1 … 1 |
|
|
(nsp014) |
|
|
@typeCode
|
|
1 … 1 |
F |
PRF |
hl7:assignedEntity
|
|
1 … 1 |
|
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
ASSIGNED |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900829 CDA Assigned Entity Identification (DYNAMISCH)
|
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.1']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
UZI |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.1 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.20.1" extension="KG56475673"/> |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.45.768.34212.34.323"/> |
hl7:code
|
CE |
1 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
hl7:addr
|
AD |
0 … * |
|
|
(nsp014) |
hl7:telecom
|
TEL |
0 … * |
|
|
(nsp014) |
hl7:assignedPerson
|
|
1 … 1 |
|
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
PSN |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
hl7:name
|
PN |
1 … * |
|
|
(nsp014) |
hl7:representedOrganization
|
|
1 … 1 |
|
|
(nsp014) |
Inclusie |
|
|
van 2.16.840.1.113883.2.4.3.36.10.900809 CDA represented organization (DYNAMISCH)
|
@classCode
|
|
1 … 1 |
F |
ORG |
@determinerCode
|
|
1 … 1 |
F |
INSTANCE |
Keuze |
1 … |
|
Elementen om uit te kiezen:
- hl7:id[@root = '2.16.528.1.1007.3.3']
- hl7:id
|
hl7:id
|
II |
0 … 1 |
|
URA |
(nsp014) |
|
|
@root
|
|
1 … 1 |
F |
2.16.528.1.1007.3.3 |
hl7:id
|
II |
0 … * |
|
Other IDs |
(nsp014) |
|
Voorbeeld |
<id root="2.16.840.1.113883.2.4.3.23.3.1234"/> |
hl7:name
|
ON |
1 … 1 |
M |
|
(nsp014) |
|
|
hl7:addr
|
AD |
0 … 1 |
|
|
(nsp014) |
|
|
hl7:telecom
|
TEL |
0 … * |
|
|
(nsp014) |
lab:code
|
CE |
0 … 1 |
|
|
(nsp014) |
|
|
|
CONF |
|
hl7:component
|
|
|
|
|
(nsp014) |
@typeCode
|
|
1 … 1 |
F |
COMP |
@contextConductionInd
|
|
1 … 1 |
F |
true |
|
Voorbeeld |
<component typeCode="COMP" contextConductionInd="true"/> |
hl7:structuredBody
|
|
|
|
|
(nsp014) |
@classCode
|
|
1 … 1 |
F |
DOCBODY |
@moodCode
|
|
1 … 1 |
F |
EVN |
|
Voorbeeld |
<structuredBody classCode="DOCBODY" moodCode="EVN"/> |
hl7:component
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.200 Clinical Information Section (DYNAMISCH)
|
(nsp014) |
|
|
|
waar [hl7:section [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.36.10.200']]] |
|
|
@typeCode
|
|
1 … 1 |
F |
COMP |
@contextConductionInd
|
|
1 … 1 |
F |
true |
hl7:component
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.210 Macroscopie (DYNAMISCH)
|
(nsp014) |
|
|
|
waar [hl7:section [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.36.10.210']]] |
|
|
@typeCode
|
|
1 … 1 |
F |
COMP |
@contextConductionInd
|
|
1 … 1 |
F |
true |
hl7:component
|
|
0 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.211 Microscopie (DYNAMISCH)
|
(nsp014) |
|
|
|
waar [hl7:section [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.36.10.211']]] |
|
|
@typeCode
|
|
1 … 1 |
F |
COMP |
@contextConductionInd
|
|
1 … 1 |
F |
true |
hl7:component
|
|
1 … 1 |
|
Bevat 2.16.840.1.113883.2.4.3.36.10.212 Diagnosis Section (2015‑02‑14)
|
(nsp014) |
|
|
|
waar [hl7:section [hl7:templateId [@root = '2.16.840.1.113883.2.4.3.36.10.212']]] |
|
|
@typeCode
|
|
1 … 1 |
F |
COMP |
@contextConductionInd
|
|
1 … 1 |
F |
true |