Acest document contine specificatii tehnice despre structura informatiilor tranzactionate in proiectul Dosarul Electronic de Sanatate - Date Medicale Relevante, despre continutul acestora si descrie documentele medicale clasice din sistem transpuse comform standardului HL7 CDA, in vederea interschimbarii lor intre diferite sisteme informatice. Structurarea informatiilor tranzactionate se face conform standardului HL7 CDA.
HL7 (Health Level Seven) este una dintre organizatiile American National Standards Institute (ANSI) – Standard Developing Organization (SDOs) acreditate in domeniul medical. Cele mai multe SDOs produc standarde (specificatii sau protocoale) pentru domenii medicale particulare, cum ar fi tranzactiile referitoare la farmacie, aparatura medicala, imagistica sau contracte de asigurare. HL7 este un domeniu clinic si administrativ. Dezvolta specificatii, fiind un standard de mesagerie care permite comunicarea aplicatiilor medicale de a schimba intre ele date clinice si administrative.
Modelul de date pentru documentele clinice tranzactionate este conform HL7.
HL7 CDA (Clinical Document Architecture) este standard markup pentru documente care specifica structura si semantica documentelor clinice cu scopul de a fi trazactionat. Limbajul markup folosit pentru codificarea documentelor CDA este Extensible Markup Language (XML). Continutul documentelor este comform HL7 Reference Information Model (RIM) si se folosesc tipurile de date din standardul HL7 v.3.
Scopul CDA este standardizarea documentelor clinice pentru a putea fi tranzactionate. Un mare avantaj pentru CDA este posibilitatea de a oferi utilizatorului o vizualizare simpla si lizibila a informatiilor medicale.
Un document CDA contine un element <ClinicalDocument>, care contine un antet (header) si un corp (body). Antetul indentifica si clasifica documentul, dar si ofera informatii despre autentificare, vizita si contextul clinic, pacient si despre furnizorul care ofera serviciile medicale. Corpul documentului contine raportul clinic, care poate fi structurat sau nestructurat; documentele structurate folosesc elementul <structuredBody> si unul sau mai multe elemente <section>. O sectiune CDA poate sa contina un singur bloc narativ, oricate elemente „CDA entries” (Entry Acts) si oricate referinte externe. Blocul narativ este specificat prin elementul <text>. Elementele „CDA entries” pot contine la randul lor alte elemente „CDA entries” si pot referi obiecte externe. Obiectele externe care pot fi referite sunt: imagini, alte proceduri sau observatii.
<ClinicalDocument>
... antet document CDA ...
<structuredBody>
... inceput corp document CDA ...
<section>
<text>...</text>
<observation>...</observation>
<substanceAdministration>
<supply>...</supply>
</substanceAdministration>
<observation>
<externalObservation>...</externalObservation>
</observation>
</section>
<section>
<section>...</section>
</section>
... sfarsit corp document CDA ...
</structuredBody>
</ClinicalDocument>
Figura 1. Componentele majore ale unui document CDA
Fiecare element al unei sectiuni CDA este compus folosind unul din tipurile HL7 (a se vedea: Tipuri de date) si in cazul in care valoarea selectata este un cod (ex: CD, CE, CV, CS), urmatoarele informatii sunt furnizate:
Set de valori: Numele unui vocabular existent (ex: HL7 AdministrativeGender) sau numele unui vocabular propriu.
Sistem de codificare: Numele unui sistem de codificare recunoscut de HL7, cum ar fi: SNOMED, LOINC, ICD10, etc.
Valoare (fixata): In cazul in care se accepta doar un cod, se va insera doar valoarea lui numerica, precum si unele informatii despre acesta (numele conceptului, numele sistem de codificare din care provine, etc).
Sabloanele reprezinta seturi de constrangeri aplicate peste elementele din structura CDA, in scopul de a defini modul permis de reprezentare al unui document CDA cu un scop bine definit. Ele sunt organizate in acest ghid dupa tipul acestora, existand:
· - Sabloane de document – capitolul „Documente”
· - Sabloane de sectiune – capitolul „Sectiuni”
· - Alte sabloane
In cadrul unui capitol, sabloanele sunt aranjate alfabetic. Sabloanele pot avea un sablon parinte („superclasa”). Pentru ca un document sau un fragment de document CDA sa respecte un sablon, trebuie sa respecte si sablonul parinte al acestuia (recursiv).
Daca o instanta reprezentand un fragment sau un intreg document CDA contine o valoare pentru identificatorul de template (elementul <templateId>), atunci ea se supune sablonului identificat astfel, trebuind sa satisfaca toate constrangerile definite de sablon pentru a fi conforma cu acesta. Identificatorul de sablon trebuie sa fie unic.
Creatorul documentului CDA poate aplica un templateId pentru a declara conformitatea cu un anumit sablon. Necesitatea aplicarii unui templateId pentru conformitate este definita in cadrul ghidurilor de implementare CDA.
Primitorul documentului CDA poate accepta sau poate refuza o instanta care nu contine un templateId valid.
Un document CDA este format din doua parti esentiale, antent si corp.
Antetul CDA-ului este continut in toate documentele CDA indiferent de tipul documentului, identifica si clasifica documentul si furnizeaza informatia la autentificare: vizita, pacientul si furnizorii implicati.
Corpul contine raportul clinic si poate fi o combinatie intre textul structurat si/sau elemente xml structurate. Fiecare sectiune din corpul documentului CDA poate fi doar text sau poate avea elemente discrete de date impreuna cu textul.
Rolul de cardinalitate exista pentru fiecare sectiune si fiecare element individual de date dintr-o sectiune. Cardinalitatea este reprezentata de 0, 1, 2 sau *, acesta din urma indicand cardinalitatea maxima. De exemplu 0..* indica o cardinalitate minima 0 si o cardinalitate maxima de oricate elemente.
Urmatorul tabel exemplifica diferitele tipuri de cardinalitate care pot fi definite pentru sectiuni si elemente de date.
|
Cardinalitate |
Descriere |
|
0..1 |
Sectiunea si elementele de date pot avea 0 sau o instanta |
|
1..1 |
Sectiunea si elementele de date pot avea exact o singura instanta |
|
0..* |
Sectiunea si elementele de date pot avea 0 sau mai multe instante |
|
1..* |
Sectiunea si elementele de date pot avea 1 sau mai multe instante |
|
2..2 |
Sectiunea si elementele de date pot avea exact doua instante |
Detaliile fiecarei sectiuni si fiecarui element de date dintr-o sectiune sunt definite prin intermediul unei constrangeri – care acopera cardinalitatea elementului si tipul de date pe care acesta trebuie sa il aiba. Constrangerea referitoare de element are un nivel de severitate - obligatoriu, recomandat sau permis.
Nivelul de severitate „obligatoriu” pentru o constrangere, aplicat unei sectiuni sau unui element de date n (ex: un element cu cardinalitate 1..* si tipul CE) indica faptul ca aceasta constrangere este o cerinta necesara pentru ca documentul sa fie conform cu sablonul definit. Ambele conditii – cea de cardinalitate si cea de tip – trebuie respectate pentru ca intreaga constrangere sa fie respectata. Neconformitatea cu sablonul este calificata ca „eroare”. Exemple: O constrangere obligatorie 1..1 cere ca un element sa aiba o aparitie si numai una. O constrangere obligatorie 0..1 permite aparitia a maxim unul element; lipsa elementului este acceptata, dar introducerea a 2 sau mai multe astfel de elemente este considerata eroare de conformitate cu sablonul. O constrangere obligatorie 1..* cere aparitia a cel putin unui element. Singurul caz de eroare este cel in care elementul lipseste (nu exista nici o instanta a lui).
Nivelul de severitate „recomandat” indica o cerinta care este de dorit a fi respectata. Chiar daca documentul nu respecta constrangerea, el este in continuare valid cu sablonul definit. Neconformitatea cu sablonul este calificata ca „avertizare”.
Nivelul de severitate „permis” indica o cerinta care ar putea fi respectata, dar optionala. Neconformitatea cu sablonul este calificata ca „informare”.
Fiecare element de date are un tip de data asociat. Urmatorul tabel indica descrierile HL7 ale tipurilor de date folosite in documentele CDA.
|
Tipul de date |
Nume |
Descriere |
|
AD |
Adresa postala |
Adresa postala de acasa sau de la servici. O secventa ale partilor unei adrese, cum ar fi strada si numar, orasul, codul postal, tara. |
|
ANY |
Orice |
Defineste proprietatile de baza ale fiecarui tip de date. Acesta este un tip abstract si nu poate fi instantiat. Fiecare tip concret este o specializare a lui ANY. |
|
BL |
Valoare booleana |
Defineste
o valoare logica cu doua posibilitati: adevarat sau fals. Ca orice alta valoare, poate fi si null.
|
|
CD |
Descrierea conceptului |
Un
CD reprezinta orice tip de concept avand un cod definit intr-un sistem de
codificare (vocabular sau nomenclator). Un CD poate contine textul original
sau fraza care serveste ca baza de codificare si una sau mai multe
translatari in diferite sisteme de codificare. Un CD poate de asemenea
contine calificari pentru descriere. De exemplu, conceptul “picior stang”
este creat din codul “picior” si calificatorul “stang”. In cazuri
exceptionale descrierea conceptului poate sa nu contina codul ci doar textul
original descris in concept.
|
|
CE |
Codificare cu echivalenti |
Date
codificate care contin valori codificate (CV) si optional valori codate din
alte coding system-uri care identifica acelasi concept. Folosite cand coduri
alternative ar putea exista.
|
|
CS |
Valori codate simple |
Date
codate in formele lor simple, unde doar codul nu este predeterminat. Code
system-ul si versiunea code system-ului este fixata in context unde apare
valoare CS-ului.
|
|
CV |
Valori codificate |
Date
codate specificand un cod si un sistem de codificare, optional si descrierea
text a codului.
|
|
ED |
Date encapsulate |
Date care sunt intentionate pentru interpretarea umana sau pentru o procesare ulterioara in afara scopului HL7. Aceasta include text formatat sau neformatat, date multimedia sau informatii structurale definite de diferite standarde. |
|
EN |
Numele entitatii |
Numele unei persoane, organizatie, loc sau lucru. O secventa de parti din nume cum ar fi numele sau prenumele, sufixul, prefixul, etc. |
|
II |
Identificatorul instantei |
Un
identificator unic pentru un lucru sau un obiect. Exemple sunt obiectele
identificate pentru obiectele HL7 RIM, numele inregistrarilor medicale,
Identificatorul cererii, Identificatorul unui element din catalogul cu
servicii, numarul de identificare al vehicolului (VIN), etc. Identificatorii
instantelor sunt definiti pe baza identificatorilor de obiecte ISO.
|
|
IVL |
Interval |
Un set de valori consecutive ale unui tip de date de baza ordonat. Fiecare tip ordonat poate fi baza unui interval. Nu conteaza daca tipul de baza este discret sau continuu. Daca tipul de baza este partial ordonat, toate elementele din interval trebuie sa fie elemente ale unui subset total ordonat. |
|
IVL_TS |
Interval de timp |
Un
set de informatii consecutive de puncte in timp.
|
|
ON |
Numele organizatiei |
Un EN utilizat cand entitatea este o organizatie. O secventa de parti de nume. |
|
PN |
Nume personal |
Un EN utilizat cand entitatea este o persoana. O seceventa de parti de nume, cum ar fi nume sau prenume, prefix, sufix, etc. |
|
PQ |
Cantitatea fizica |
O cantitate dimensionata care exprima rezultatul unei masuratori. |
|
ST |
Caracter string |
Un sir de caractere facut in primul rand pentru procesarea de catre calculator (sortare, indexare, interogare, etc). Folosit pentru nume, simboluri si expresii formale. |
|
TEL |
Adrese de telecomunicare |
Un numar de telefon (voce sau fax), adresa de e-mail, sau alte locatii care folosesc echimpamente de telecomunicatii. Adresa este specificata ca Universal Resource Locator (URL) calificat de specificatiile timpului si care foloseste coduri care ajuta la deciderea carei adrese sa fie folosite la un moment dat si scop. A se nota ca spatiile din acest tip de date nu sunt valide, desi aceasta nu este momentan constransa de HL7. |
|
TS |
Timestamp |
O
cantitate care specifica un punct aflat pe o axa a timpului. Un punct in timp
este adesea reprezentat de o expresie calendaristica. Nota: un IVL_TS
(Interval Timestamp) trebuie sa fie total format, pentru ca un TS sa fie
delimitat. |
Vocabularele sunt listele de codificare, cunoscute si sub numele de nomenclatoare. In HL7 poarta numele de sisteme de codificare (coding systems).
O valoare dintr-un vocabular este identificata unic cu ajutorul a doua informatii:
Alte elemente necesare unei valori codate dintr-un vocabular:
Entitatile sunt obiecte din lumea reala (persoane, sectii, etc), care trebuie identificate unic, dar care nu fac parte dintr-un vocabular predefinit deoarece sunt create de o anumita institutie.
Exemple de entitati in acceptiunea HL7 sunt: organizatiile, persoanele, departamentele, etc.
O entitate este identificata unic cu ajutorul a doua informatii:
Valoarea unui “root” reprezinta OID-ul (ex: 2.16.840.1.113883.3.270, obtinut de la http://www.hl7.org/oid/index.cfm) pentru modelele HL7 inregistrate. Pentru modelele proprii neinregistrare, valorea „root” este „2.16.840.1.113883.3.3368” - OID root pentru Casa Nationala de Sanatate, Romania.
Valoarea unui “extension” reprezinta identificatorul unic pentru entitate.
Subclase: EmergencySummaryOutDocument, PatientInformationOutDocument, ReportedMedicalHistoryOutDocument, MedicalHistoryOutDocument, MedicalEventsOutDocument
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| code | 1..1 | CE | Codul documentului
|
| confidentialityCode | 1..1 | CE | Nivelul de confidentialitate
Valoare: selectie din Set de valori ConfidentialityCode |
| effectiveTime | 1..1 | TS | Momentul crearii documentului (@value - data crearii)
|
| id | 1..1 | II | Identificator intern al documentului (@root='2.16.840.1.113883.3.3368', @extension - identificator unic)
|
| languageCode | 0..1 | CS | Limba
Valoare: selectie din Set de valori HumanLanguage |
| title | 1..1 | ST | Numele documentului
|
| author | 1..1 | Author | Autor
|
| > time | 1..1 | TS | Data crearii documentului (@value - data crearii)
|
| > assignedAuthor | 1..1 | AssignedAuthor | |
| > id | 1..1 | II | Identificatorul autorului documentului - sistemul DES (@root="2.16.840.1.113883.3.3368")
|
| > assignedAuthoringDevice | 0..1 | AuthoringDevice | |
| > softwareName | 1..1 | SC | Numele software-ului (DES) care genereaza acest document prin consolidarea datelor primite
|
| custodian | 1..1 | Custodian | Organizatia responsabila cu gestiunea acestui document
|
| > assignedCustodian | 1..1 | AssignedCustodian | |
| > representedCustodianOrganization | 1..1 | CustodianOrganization | |
| > id | 1..1 | II | Identificatorul organizatiei responsabile cu gestiunea acestui document (@root="2.16.840.1.113883.3.3368")
|
| > name | 0..1 | ON | Numele organizatiei responsabile cu gestiunea acestui document
|
| recordTarget | 1..1 | RecordTarget | |
| typeId | 1..1 | InfrastructureRootTypeId | |
| component/structuredBody | 1..1 |
Superclase: DMRClinicalDocument
Document Sumar DES
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.8.1" |
| code | 1..1 | CE | Valoare: fixa @code="60591-5" Sumar (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| confidentialityCode | 1..1 | CE | Nivelul de confidentialitate
Valoare: selectie din Set de valori ConfidentialityCode |
| effectiveTime | 1..1 | TS | Momentul crearii documentului (@value - data crearii)
|
| id | 1..1 | II | Identificator intern al documentului (@root='2.16.840.1.113883.3.3368', @extension - identificator unic)
|
| languageCode | 0..1 | CS | Limba
Valoare: selectie din Set de valori HumanLanguage |
| title | 1..1 | ST | Numele documentului
|
| author | 1..1 | Author | Autor
|
| > time | 1..1 | TS | Data crearii documentului (@value - data crearii)
|
| > assignedAuthor | 1..1 | AssignedAuthor | |
| > id | 1..1 | II | Identificatorul autorului documentului - sistemul DES (@root="2.16.840.1.113883.3.3368")
|
| > assignedAuthoringDevice | 0..1 | AuthoringDevice | |
| > softwareName | 1..1 | SC | Numele software-ului (DES) care genereaza acest document prin consolidarea datelor primite
|
| custodian | 1..1 | Custodian | Organizatia responsabila cu gestiunea acestui document
|
| > assignedCustodian | 1..1 | AssignedCustodian | |
| > representedCustodianOrganization | 1..1 | CustodianOrganization | |
| > id | 1..1 | II | Identificatorul organizatiei responsabile cu gestiunea acestui document (@root="2.16.840.1.113883.3.3368")
|
| > name | 0..1 | ON | Numele organizatiei responsabile cu gestiunea acestui document
|
| recordTarget | 1..1 | RecordTarget | |
| typeId | 1..1 | InfrastructureRootTypeId | |
| component/structuredBody | 1..1 | ||
| > component / section | 0..1 | BloodTypeOutSection | Grupa sanguina
|
| > component / section | 0..1 | EmergencyInformationOutSection | Sectiune Informatii pentru urgente
|
| > component / section | 0..1 | PatientConsentOutSection | Sectiune Informatii furnizate de pacient
|
Superclase: DMRClinicalDocument
Document Istoric evenimente medicale
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.8.5" |
| code | 1..1 | CE | Valoare: fixa @code="11503-0" Istoric evenimente medicale (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| confidentialityCode | 1..1 | CE | Nivelul de confidentialitate
Valoare: selectie din Set de valori ConfidentialityCode |
| effectiveTime | 1..1 | TS | Momentul crearii documentului (@value - data crearii)
|
| id | 1..1 | II | Identificator intern al documentului (@root='2.16.840.1.113883.3.3368', @extension - identificator unic)
|
| languageCode | 0..1 | CS | Limba
Valoare: selectie din Set de valori HumanLanguage |
| title | 1..1 | ST | Numele documentului
|
| author | 1..1 | Author | Autor
|
| > time | 1..1 | TS | Data crearii documentului (@value - data crearii)
|
| > assignedAuthor | 1..1 | AssignedAuthor | |
| > id | 1..1 | II | Identificatorul autorului documentului - sistemul DES (@root="2.16.840.1.113883.3.3368")
|
| > assignedAuthoringDevice | 0..1 | AuthoringDevice | |
| > softwareName | 1..1 | SC | Numele software-ului (DES) care genereaza acest document prin consolidarea datelor primite
|
| custodian | 1..1 | Custodian | Organizatia responsabila cu gestiunea acestui document
|
| > assignedCustodian | 1..1 | AssignedCustodian | |
| > representedCustodianOrganization | 1..1 | CustodianOrganization | |
| > id | 1..1 | II | Identificatorul organizatiei responsabile cu gestiunea acestui document (@root="2.16.840.1.113883.3.3368")
|
| > name | 0..1 | ON | Numele organizatiei responsabile cu gestiunea acestui document
|
| recordTarget | 1..1 | RecordTarget | |
| typeId | 1..1 | InfrastructureRootTypeId | |
| component/structuredBody | 1..1 | ||
| > component / section | 0..1 | HospitalAdmissionDetailsOutSection | Sectiune Istoric internari
|
| > component / section | 0..1 | PrescriptionDetailsOutSection | Sectiune Istoric retete
|
| > component / section | 0..1 | PrimaryCareConsultationHistoryOutSection | Sectiune Istoric consultatii la MF
|
| > component / section | 0..1 | ReferralDetailsOutSection | Sectiune Istoric trimiteri
|
| > component / section | 0..1 | SpecialistConsultationHistoryOutSection | Sectiune Istoric consultatii pe specialitati
|
Superclase: DMRClinicalDocument
Document Istoric medical
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.8.4" |
| code | 1..1 | CE | Valoare: fixa @code="34117-2" Istoric medical (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| confidentialityCode | 1..1 | CE | Nivelul de confidentialitate
Valoare: selectie din Set de valori ConfidentialityCode |
| effectiveTime | 1..1 | TS | Momentul crearii documentului (@value - data crearii)
|
| id | 1..1 | II | Identificator intern al documentului (@root='2.16.840.1.113883.3.3368', @extension - identificator unic)
|
| languageCode | 0..1 | CS | Limba
Valoare: selectie din Set de valori HumanLanguage |
| title | 1..1 | ST | Numele documentului
|
| author | 1..1 | Author | Autor
|
| > time | 1..1 | TS | Data crearii documentului (@value - data crearii)
|
| > assignedAuthor | 1..1 | AssignedAuthor | |
| > id | 1..1 | II | Identificatorul autorului documentului - sistemul DES (@root="2.16.840.1.113883.3.3368")
|
| > assignedAuthoringDevice | 0..1 | AuthoringDevice | |
| > softwareName | 1..1 | SC | Numele software-ului (DES) care genereaza acest document prin consolidarea datelor primite
|
| custodian | 1..1 | Custodian | Organizatia responsabila cu gestiunea acestui document
|
| > assignedCustodian | 1..1 | AssignedCustodian | |
| > representedCustodianOrganization | 1..1 | CustodianOrganization | |
| > id | 1..1 | II | Identificatorul organizatiei responsabile cu gestiunea acestui document (@root="2.16.840.1.113883.3.3368")
|
| > name | 0..1 | ON | Numele organizatiei responsabile cu gestiunea acestui document
|
| recordTarget | 1..1 | RecordTarget | |
| typeId | 1..1 | InfrastructureRootTypeId | |
| component/structuredBody | 1..1 | ||
| > component / section | 0..1 | AllergiesOutSection | Sectiune Alergii
|
| > component / section | 0..1 | ChronicDiseaseDetailsOutSection | Sectiune Boli cronice
|
| > component / section | 0..1 | ClinicalTrialOutSection | Sectiune Tratamente in cadrul Studiilor Clinice
|
| > component / section | 0..1 | DiseaseOutSection | Sectiune Istoric Boli/Diagnostice
|
| > component / section | 0..1 | ImmunizationsOutSection | Sectiune Imunizari
|
| > component / section | 0..1 | MedicalServicesOutSection | Sectiune Servicii clinice, paraclinice si spitalicesti
|
| > component / section | 0..1 | ProceduresOutSection | Sectiune Interventii si proceduri efectuate
|
Superclase: DMRClinicalDocument
Document Date de identificare pacient
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.8.2" |
| code | 1..1 | CE | Valoare: fixa @code="52460-3" Date de identificare pacient (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| confidentialityCode | 1..1 | CE | Nivelul de confidentialitate
Valoare: selectie din Set de valori ConfidentialityCode |
| effectiveTime | 1..1 | TS | Momentul crearii documentului (@value - data crearii)
|
| id | 1..1 | II | Identificator intern al documentului (@root='2.16.840.1.113883.3.3368', @extension - identificator unic)
|
| languageCode | 0..1 | CS | Limba
Valoare: selectie din Set de valori HumanLanguage |
| title | 1..1 | ST | Numele documentului
|
| author | 1..1 | Author | Autor
|
| > time | 1..1 | TS | Data crearii documentului (@value - data crearii)
|
| > assignedAuthor | 1..1 | AssignedAuthor | |
| > id | 1..1 | II | Identificatorul autorului documentului - sistemul DES (@root="2.16.840.1.113883.3.3368")
|
| > assignedAuthoringDevice | 0..1 | AuthoringDevice | |
| > softwareName | 1..1 | SC | Numele software-ului (DES) care genereaza acest document prin consolidarea datelor primite
|
| custodian | 1..1 | Custodian | Organizatia responsabila cu gestiunea acestui document
|
| > assignedCustodian | 1..1 | AssignedCustodian | |
| > representedCustodianOrganization | 1..1 | CustodianOrganization | |
| > id | 1..1 | II | Identificatorul organizatiei responsabile cu gestiunea acestui document (@root="2.16.840.1.113883.3.3368")
|
| > name | 0..1 | ON | Numele organizatiei responsabile cu gestiunea acestui document
|
| recordTarget | 1..1 | RecordTarget | |
| typeId | 1..1 | InfrastructureRootTypeId | |
| component/structuredBody | 1..1 | ||
| > component / section | 0..1 | BloodTypeOutSection | Grupa sanguina
|
| > component / section | 0..1 | DeathCertificateOutSection | Informatii deces
|
| > component / section | 0..1 | InsuranceInformationOutSection | Informatii asigurare medicala
|
Superclase: DMRClinicalDocument
Document Antecedente
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.8.3" |
| code | 1..1 | CE | Valoare: fixa @code="67804-5" Antecedente (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| confidentialityCode | 1..1 | CE | Nivelul de confidentialitate
Valoare: selectie din Set de valori ConfidentialityCode |
| effectiveTime | 1..1 | TS | Momentul crearii documentului (@value - data crearii)
|
| id | 1..1 | II | Identificator intern al documentului (@root='2.16.840.1.113883.3.3368', @extension - identificator unic)
|
| languageCode | 0..1 | CS | Limba
Valoare: selectie din Set de valori HumanLanguage |
| title | 1..1 | ST | Numele documentului
|
| author | 1..1 | Author | Autor
|
| > time | 1..1 | TS | Data crearii documentului (@value - data crearii)
|
| > assignedAuthor | 1..1 | AssignedAuthor | |
| > id | 1..1 | II | Identificatorul autorului documentului - sistemul DES (@root="2.16.840.1.113883.3.3368")
|
| > assignedAuthoringDevice | 0..1 | AuthoringDevice | |
| > softwareName | 1..1 | SC | Numele software-ului (DES) care genereaza acest document prin consolidarea datelor primite
|
| custodian | 1..1 | Custodian | Organizatia responsabila cu gestiunea acestui document
|
| > assignedCustodian | 1..1 | AssignedCustodian | |
| > representedCustodianOrganization | 1..1 | CustodianOrganization | |
| > id | 1..1 | II | Identificatorul organizatiei responsabile cu gestiunea acestui document (@root="2.16.840.1.113883.3.3368")
|
| > name | 0..1 | ON | Numele organizatiei responsabile cu gestiunea acestui document
|
| recordTarget | 1..1 | RecordTarget | |
| typeId | 1..1 | InfrastructureRootTypeId | |
| component/structuredBody | 1..1 | ||
| > component / section | 0..1 | AdultPhysiologicalHistoryOutSection | Sectiune Antecedente personale fiziologice (adult-femei)
|
| > component / section | 0..1 | ChildPhysiologicalHistoryOutSection | Sectiune Antecedente personale fiziologice (copii)
|
| > component / section | 0..1 | FamilyHistoryOutSection | Sectiune Antecedente heredo-colaterale
|
| > component / section | 0..1 | PersonalPathologicalHistoryOutSection | Sectiune Antecedente personale patologice
|
| > component / section | 0..1 | SocialHistoryOutSection | Sectiune Mod de viata
|
Utilizari (1):
ReportedMedicalHistoryOutDocument
Sectiune Antecedente personale fiziologice (adult-femei)
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.97" |
| code | 1..1 | CE | Valoare: fixa @code="34117-3" Antecedente personale fiziologice (adult femei) (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entry / act | 0..1 | AbortionsSummaryOutAct | |
| entry / act | 0..1 | LaborAndDeliveryOutAct | |
| entry / act | 0..1 | MenarcheOutAct | |
| entry / act | 0..1 | MenopauseOutAct | |
| entry / act | 0..1 | PregnancyEvolutionOutAct |
Utilizari (1):
MedicalHistoryOutDocument
Sectiune Alergii
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.158" |
| code | 1..1 | CE | Valoare: fixa @code="48765-2" Alergii (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / observation | 1..* | AllergyOutObservation |
Utilizari (2):
EmergencySummaryOutDocument
PatientInformationOutDocument
Grupa sanguina
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.39" |
| code | 1..1 | CE | Valoare: fixa @code="882-1" Grupa sanguina (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / observation | 0..1 | BloodABOTypeOutObservation | |
| entry / observation | 0..1 | BloodRhTypeOutObservation |
Utilizari (1):
ReportedMedicalHistoryOutDocument
Sectiune Antecedente personale fiziologice (copii)
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.113" |
| code | 1..1 | CE | Valoare: fixa @code="68817-6" Antecedente personale fiziologice (copil) (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / act | 0..1 | ApgarScoreOutAct | |
| entry / act | 0..1 | BirthDetailsOutAct | |
| entry / act | 0..1 | BirthWeightOutAct | |
| entry / act | 0..1 | NewbornNutritionOutAct |
Utilizari (1):
MedicalHistoryOutDocument
Sectiune Boli cronice
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.165" |
| code | 1..1 | CE | Valoare: fixa @code="54531-2" Boli cronice (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entry / observation | 1..* | ChronicDiseaseDetailsOutObservation |
Utilizari (1):
MedicalHistoryOutDocument
Sectiune Tratamente in cadrul Studiilor Clinice
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.161" |
| code | 1..1 | CE | Valoare: fixa @code="35510-7" Tratament medicamentos acordat in cadrul unor studii clinice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / observation | 1..* | ClinicalTrialDetailsOutObservation |
Utilizari (1):
PatientInformationOutDocument
Informatii deces
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.42" |
| code | 1..1 | CE | Valoare: fixa @code="64297-5" Certificat de deces (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / observation | 1..1 | DeceasedDateOutObservation |
Utilizari (1):
MedicalHistoryOutDocument
Sectiune Istoric Boli/Diagnostice
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.157" |
| code | 1..1 | CE | Valoare: fixa @code="29308-4" Diagnostic (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / observation | 1..* | DiseaseOutObservation |
Utilizari (1):
EmergencySummaryOutDocument
Sectiune Informatii pentru urgente
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.16" |
| code | 1..1 | CE | Valoare: fixa @code="55752-0" Informatii pentru urgente (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / act | 0..1 | AllergiesAllOutAct | |
| entry / act | 0..1 | ArteriovenousFistulaAllOutAct | |
| entry / act | 0..1 | ChronicDiseasesOutAct | |
| entry / act | 0..1 | CurrentMedicationOutAct | |
| entry / act | 0..1 | HematologicDiseasesAllOutAct | |
| entry / act | 0..1 | HospitalAdmissionOutAct | |
| entry / act | 0..1 | ProstheticsOutAct | |
| entry / act | 0..1 | SurgicalProceduresOutAct | |
| entry / act | 0..1 | TransmissibleDiseasesAllOutAct | |
| entry / act | 0..1 | TransplantationOutAct |
Utilizari (1):
ReportedMedicalHistoryOutDocument
Sectiune Antecedente heredo-colaterale
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.135" |
| code | 1..1 | CE | Valoare: fixa @code="10157-6" Antecedente heredo-colaterale (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / act | 0..1 | FamilyMemberDeathReasonOutAct | |
| entry / act | 0..1 | FamilyMemberPathologyOutAct | |
| entry / act | 0..1 | HereditaryDiseasesOutAct |
Utilizari (1):
MedicalEventsOutDocument
Sectiune Istoric internari
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.196" |
| code | 1..1 | CE | Valoare: fixa @code="67852-2" Internari (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entry / observation | 1..* | HospitalAdmissionDetailsOutObservation |
Utilizari (1):
MedicalHistoryOutDocument
Sectiune Imunizari
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.139" |
| code | 1..1 | CE | Valoare: fixa @code="11369-6" Imunizari (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / substanceAdministration | 1..* | ImmunizationOutAdministration |
Utilizari (1):
PatientInformationOutDocument
Informatii asigurare medicala
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.44" |
| code | 1..1 | CE | Valoare: fixa @code="64291-1" Informatii despre asigurarea medicala (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entry / observation | 1..1 | InsuranceHouseOutObservation |
Utilizari (1):
MedicalHistoryOutDocument
Sectiune Servicii clinice, paraclinice si spitalicesti
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.160" |
| code | 1..1 | CE | Valoare: fixa @code="29300-4" Servicii medicale (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entry / organizer | 0..1 | ClinicalServiceOutOrganizer | |
| entry / organizer | 0..1 | HospitalServiceOutOrganizer | |
| entry / organizer | 0..1 | LaboratoryServiceOutOrganizer |
Utilizari (1):
EmergencySummaryOutDocument
Sectiune Informatii furnizate de pacient
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.2" |
| code | 1..1 | CE | Valoare: fixa @code="59284-0" Indicatii furnizate de pacient (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / organizer | 0..1 | BloodTransfusionConsentOutOrganizer | |
| entry / organizer | 0..1 | OrganDonationConsentOutOrganizer | |
| entry / organizer | 0..1 | ResuscitationConsentOutOrganizer |
Utilizari (1):
ReportedMedicalHistoryOutDocument
Sectiune Antecedente personale patologice
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.92" |
| code | 1..1 | CE | Valoare: fixa @code="11348-0" Antecedente personale patologice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / act | 0..1 | AllergiesSummaryReportedOutAct | |
| entry / act | 0..1 | ArteriovenousFistulaOutAct | |
| entry / act | 0..1 | ChronicDiseasesHistorySummaryOutAct | |
| entry / act | 0..1 | DiseasesHistorySummaryOutAct | |
| entry / act | 0..1 | HematologicDiseasesSummaryOutAct | |
| entry / act | 0..1 | ImmunizationsHistorySummaryOutAct | |
| entry / act | 0..1 | ProceduresHistorySummaryOutAct | |
| entry / act | 0..1 | ProstheticsSummaryOutAct | |
| entry / act | 0..1 | TransmissibleDiseasesSummaryOutAct | |
| entry / act | 0..1 | TransplantationHistorySummaryOutAct |
Utilizari (1):
MedicalEventsOutDocument
Sectiune Istoric retete
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.200" |
| code | 1..1 | CE | Valoare: fixa @code="57828-6" Retete (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / observation | 1..* | PrescriptionDetailsOutObservation |
Utilizari (1):
MedicalEventsOutDocument
Sectiune Istoric consultatii la MF
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.191" |
| code | 1..1 | CE | Valoare: fixa @code="68834-3" Istoric consultatii MF (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entry / observation | 1..* | PrimaryCareConsultationDetailsOutObservation |
Utilizari (1):
MedicalHistoryOutDocument
Sectiune Interventii si proceduri efectuate
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.159" |
| code | 1..1 | CE | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / procedure | 1..* | MedicalOutProcedure |
Utilizari (1):
MedicalEventsOutDocument
Sectiune Istoric trimiteri
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.204" |
| code | 1..1 | CE | Valoare: fixa @code="57133-1" Trimiteri (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / observation | 1..* | ReferralDetailsOutObservation |
Utilizari (1):
ReportedMedicalHistoryOutDocument
Sectiune Mod de viata
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.46" |
| code | 1..1 | CE | Valoare: fixa @code="29762-2" Mod de viata (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entry / act | 0..1 | AlcoholConsumptionOutAct | |
| entry / act | 0..1 | CoffeeConsumptionOutAct | |
| entry / act | 0..1 | DietOutAct | |
| entry / act | 0..1 | DrugAddictionOutAct | |
| entry / act | 0..1 | FamilyEnvironmentOutAct | |
| entry / act | 0..1 | PhysicalExercisesOutAct | |
| entry / act | 0..1 | RestOutAct | |
| entry / act | 0..1 | SmokingStatusOutAct | |
| entry / act | 0..1 | WorkConditionsOutAct |
Utilizari (1):
MedicalEventsOutDocument
Sectiune Istoric consultatii pe specialitati
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.192" |
| code | 1..1 | CE | Valoare: fixa @code="11488-2" Istoric consultatii specialist (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entry / observation | 1..* | SpecialistConsultationDetailsOutObservation |
Utilizari (1):
AdultPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.101" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11612-1" Avorturi (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | AbortionsSummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
AbortionsSummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.103" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11612-1" Avorturi (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
AbortionsSummaryOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.102" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11612-1" Avorturi (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | AbortionsSummaryOutObservation |
Utilizari (2):
MedicationPrescriptionOutSubstanceAdministration
MedicationAdministeredOutSubstanceAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.122" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="55106-1" Substanta activa (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| value | 1..1 | CD | Substanta activa continuta de medicament.
Valoare din nomenclator - Medicamente (SIUI) - Substanta activa
Valoare: selectie din Set de valori ActiveSubstances |
Utilizari (1):
HospitalAdmissionOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.208" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="46241-6" Diagnostic de internare (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Descriere diagnostic
|
| value | 1..1 | CD | Diagnostic
Valoare: selectie din Set de valori ICD10AM |
Utilizari (3):
ChronicDiseaseDetailsOutObservation
ImmunizationOutAdministration
AllergyOutObservation
Informatii despre varsta
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.48" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="30525-0" Varsta (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | PQ | Varsta exprimata in luni sau ani (@unit = "ln" sau "an")
|
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.72" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11331-6" Consum de alcool (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | AlcoholConsumptionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
AlcoholConsumptionOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.61" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11331-6" Consum de alcool (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
AlcoholConsumptionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.62" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11331-6" Consum de alcool (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | AlcoholConsumptionOutObservation |
Utilizari (1):
AllergyOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.50" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52473-1" Reactie alergica (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | Contine descrierea alergiei diagnosticate
|
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.17" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="8658-7" Istoric alergii (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | AllergiesSummaryReportedOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | AllergyOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.96" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10155-0" Alergii raportate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | AllergiesSummaryReportedOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
AllergiesSummaryReportedOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.9" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10155-0" Alergii raportate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Descriere Alergii
Va retine informatiile cu privire la alergiile sau elementele alergice (ex: medicamente, substante) comunicate de pacient sau inregistrate de medic, conform documentelor medicale furnizate de pacient
|
| value | 1..1 | BL | Alergii.
Campul se marcheaza daca pacientul prezinta alergii sau elemente alergice - Da/Nu
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
AllergiesAllOutAct
AllergiesSummaryReportedOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.14" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10155-0" Alergii raportate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | AllergiesSummaryReportedOutObservation |
Utilizari (2):
AllergiesOutSection
AllergyOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.8" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52473-6" Alergii (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| effectiveTime | 0..1 | IVL_TS | Data diagnosticare alergie (effectiveTime.low - @value)
|
| text | 0..1 | ED | Intoleranta la medicamente. substante, alimente.
Va contine informatii cu privire la alte elemente alergice pentru pacient.
|
| value | 0..1 | CD | Diagnosticul de Alergie asociat pacientului
|
| entryRelationship / observation | 0..1 | AgeObservation | Varsta la care a fost diagnosticata alergia
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | AllergicReactionObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="MFST" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
AllergiesAllOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.13" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52473-6" Alergii (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | AllergyOutObservation |
Utilizari (1):
ChildPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.119" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="9274-2" Scor apgar (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | ApgarScoreOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ApgarScoreOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.117" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="9274-2" Scor Apgar (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | INT | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
ApgarScoreOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.118" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="9274-2" Scor apgar (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ApgarScoreOutObservation |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.219" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="39040-2" Fistula arterio-venoasa (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | ArteriovenousFistulaOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | ArteriovenousFistulaProceduresOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.86" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="39040-1" Fistula arterio-venoasa (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | ArteriovenousFistulaOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ArteriovenousFistulaOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.88" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="39040-1" Fistula arterio-venoasa (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | BL | Campul marcheaza daca pacientul are fistula arterio-venoasa.
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
ArteriovenousFistulaOutAct
ArteriovenousFistulaAllOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.87" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="39040-1" Fistula arterio-venoasa (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ArteriovenousFistulaOutObservation |
Utilizari (1):
ArteriovenousFistulaAllOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.220" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="39040-3" Fistula arterio-venoasa - proceduri (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / procedure | 1..* | MedicalOutProcedure |
Utilizari (1):
PhysicianAssignedEntity
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| name | 1..1 | PN | Numele si prenumele persoanei
|
Utilizari (1):
ChronicDiseaseOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.58" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="45952-1" Program national de sanatate (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Contine obligatoriu data de includere in PNS (effectiveTime.low - @value) si optional data de excludere din PNS (effectiveTime.high - @value)
|
| text | 0..1 | ED | Motivul de excludere al pacientului din cadrul Programului National
|
| value | 1..1 | CD | Valoare: selectie din Set de valori NationalHealthProgrammes |
Utilizari (1):
ChildPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.116" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57075-4" Detalii nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | BirthDetailsOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
BirthDetailsOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.114" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57075-4" Detalii nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Nastere (naturala, cezariana, instrumentala - forceps, ventuza)
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
BirthDetailsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.115" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57075-4" Detalii nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | BirthDetailsOutObservation |
Utilizari (1):
ChildPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.122" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="8339-4" Greutate la nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | BirthWeightOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
BirthWeightOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.120" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="8339-4" Greutate la nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | PQ | Greutatea la nastere exprimata in grame (@value - numar, @unit="g")
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
BirthWeightOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.121" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="8339-4" Greutate la nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | BirthWeightOutObservation |
Utilizari (1):
BloodTypeOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.40" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="883-9" Grupa AB0 (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | CD | Valoare: selectie din Set de valori BloodABO |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
BloodTypeOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.41" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10331-7" Tip Rh (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | CD | Valoare: selectie din Set de valori BloodRh |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
BloodTransfusionConsentOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.4" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| @negationInd | 0..1 | boolean | Valoare: fixa @negationInd |
| code | 1..1 | CD | Valoare: fixa @code="56836-1" Acord cu privire la transfuzia de sange (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 0..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
PatientConsentOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.11" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="56836-1" Acord cu privire la transfuzia de sange (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | BloodTransfusionConsentOutObservation |
Utilizari (1):
ChronicDiseaseDetailsOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.162" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54531-1" Boala cronica (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 0..1 | IVL_TS | Data diagnosticarii (effectiveTime.low - @value)
|
| text | 0..1 | ED | Dispensarizare
|
| value | 1..1 | CD | Va contine Diagnosticul de Boala Cronica asociat pacientului.
Valoare din Nomenclator Diagnostice ICD10AM sau Diag999 - Cod si denumire
|
| entryRelationship / observation | 0..1 | AgeObservation | Varsta la momentul diagnosticarii
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / act | 0..1 | MedicationOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | MostRecentDateOutObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..1 | OtherTreatmentOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ChronicDiseaseOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.30" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54531-1" Boala cronica (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data la care diagnosticul este asociat pacientului (effectiveTime.low - @value)
|
| text | 0..1 | ED | Dispensarizare.
Va contine informatii si observatii suplimentare transmise de medic cu privire la boala cronica diagnosticata
|
| value | 1..1 | CD | Va contine Diagnosticul de Boala Cronica asociat pacientului.
Valoare din Nomenclator Diagnostice ICD10AM sau Diag999 - Cod si denumire
|
| entryRelationship / observation | 0..* | AssociatedNationalProgrammeObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
ChronicDiseasesOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.31" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54531-1" Boala cronica (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ChronicDiseaseOutObservation |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.95" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54531-2" Boli cronice (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | ChronicDiseasesHistorySummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ChronicDiseasesHistorySummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.28" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54531-2" Boli cronice (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | Boli Cronice
Va retine informatiile cu privire la Bolile Cronice comunicate de pacient sau inregistrate de medic conform documentelor medicale furnizate de pacient.
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
ChronicDiseasesHistorySummaryOutAct
ChronicDiseasesOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.29" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54531-2" Boli cronice (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ChronicDiseasesHistorySummaryOutObservation |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.27" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54531-3" Istoric boli cronice (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | ChronicDiseaseOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | ChronicDiseasesHistorySummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ClinicalServiceOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.143" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29300-2" Serviciu clinic (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data la care serviciul este efectuat pacientului (@value - data efectuarii)
|
| value | 1..1 | CD | Codul serviciului efectuat pacientului
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 0..1 | MedicalServiceResultAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
MedicalServicesOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.144" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29300-3" Servicii clinice (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ClinicalServiceOutObservation |
Utilizari (1):
ClinicalTrialOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.148" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="35510-7" Tratament medicamentos acordat in cadrul unor studii clinice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| effectiveTime | 1..1 | IVL_TS | Data intrarii in studiu a pacientului (effectiveTime.low - @value) - obligatorie.
Data iesirii din studiu a pacientului (effectiveTime.high - @value) - optionala.
|
| text | 1..1 | ED | Nume studiu
|
| participant | 1..1 | ClinicalTrialPrescriber | |
| entryRelationship / observation | 1..* | ClinicalTrialDrugObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
ClinicalTrialDrugObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.147" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="35517-2" Diagnostic in cadrul unui studiu clinic (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Descriere diagnostic
|
| value | 1..1 | CD | Diagnosticul pentru care respectivul medicament este administrat
Valoare: selectie din Set de valori ICD10AM |
Utilizari (1):
ClinicalTrialDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.146" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="35527-1" Medicament aflat in studiu (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Medicament si shema terapeutica
|
| entryRelationship / observation | 1..1 | ClinicalTrialDiagnosisObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ClinicalTrialDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.148" |
| @typeCode | 1..1 | ParticipationType | Valoare: fixa @typeCode="ATND" |
| participantRole | 1..1 | ClinicalTrialPrescriberRole |
Utilizari (1):
ClinicalTrialPrescriber
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.149" |
| id | 1..1 | II | Parafa medicului (@root="Parafa", @extension - parafa medic)
|
| scopingEntity | 1..1 | HealthProviderScopingEntity | |
| playingEntity | 1..1 | PhysicianPlayingEntity |
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.70" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="43829-1" Consum de cafea (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | CoffeeConsumptionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
CoffeeConsumptionOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.57" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="43829-1" Consum de cafea (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
CoffeeConsumptionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.58" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="43829-1" Consum de cafea (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | CoffeeConsumptionOutObservation |
Utilizari (2):
PrimaryCareConsultationDetailsOutObservation
SpecialistConsultationDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.156" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="39223-3" Recomandari in urma consultatiei (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Recomandari, prescriptii
|
Utilizari (65):
DeceasedDateOutObservation
AbortionsSummaryOutObservation
FamilyMemberPathologyOutObservation
BirthDetailsOutObservation
InsuranceHouseOutObservation
OrganDonationConsentOutObservation
ClinicalTrialDetailsOutObservation
ResuscitationConsentOutObservation
ChronicDiseasesHistorySummaryOutObservation
TransplantationHistorySummaryOutObservation
ImmunizationsHistorySummaryOutObservation
DietOutObservation
MedicalOutProcedure
MenopauseOutObservation
WorkConditionsOutObservation
AllergyOutObservation
IssuedLaboratoryReferralOutAct
CoffeeConsumptionOutObservation
SmokingStatusOutObservation
PhysicalExercisesOutObservation
RelatedMedicalServiceOutObservation
HematologicDiseasesSummaryOutObservation
ChronicDiseaseDetailsOutObservation
ImmunizationOutAdministration
HospitalAdmissionOutObservation
SpecialistConsultationDetailsOutObservation
ProceduresHistorySummaryOutObservation
HereditaryDiseasesOutObservation
MedicationPrescriptionOutSubstanceAdministration
DrugAddictionOutObservation
HospitalAdmissionDetailsOutObservation
TransmissibleDiseasesSummaryOutObservation
ArteriovenousFistulaOutObservation
MenarcheOutObservation
FamilyMemberDeathReasonOutObservation
NewbornNutritionOutObservation
DiseaseOutObservation
ClinicalServiceOutObservation
ChronicDiseaseOutObservation
IssuedMedicalDevicesReferralOutAct
LaboratoryServiceOutObservation
ReferralDetailsOutObservation
PrescriptionDetailsOutObservation
RestOutObservation
BloodABOTypeOutObservation
IssuedMedicationPrescriptionOutAct
BloodRhTypeOutObservation
BloodTransfusionConsentOutObservation
PregnancyEvolutionOutObservation
IssuedHomeCareReferralOutAct
IssuedClinicalReferralOutAct
DiagnosisOutObservation
AllergiesSummaryReportedOutObservation
OtherTreatmentOutObservation
AlcoholConsumptionOutObservation
ApgarScoreOutObservation
DiseasesHistorySummaryOutObservation
LaborAndDeliveryOutObservation
FamilyEnvironmentOutObservation
HospitalServiceOutObservation
MedicationAdministeredOutSubstanceAdministration
PrimaryCareConsultationDetailsOutObservation
ProstheticsSummaryOutObservation
ReceivedClinicalReferralOutAct
BirthWeightOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.5" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="context" Informatie de context (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data documentului sursa (effectiveTime - @value)
|
| text | 0..1 | ED | Alte informatii
|
| value | 1..1 | CD | value - Cod document sursa, obligatoriu. value.qualifier.value - Cod sectiune sursa, optional.
|
| participant | 0..1 | ContextParticipant | |
| reference | 0..1 | ContextReference |
Utilizari (1):
ContextObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.7" |
| @typeCode | 1..1 | ParticipationType | Valoare: fixa @typeCode |
| participantRole | 1..1 | ParticipantRole | |
| > id | 0..1 | II | Parafa medic (@root="Parafa", @extension - parafa medic)
|
| > playingEntity | 1..1 | PlayingEntity | |
| > code | 0..1 | CE | Specialitate
Valoare: selectie din Set de valori MedicalSpecialities |
| > desc | 0..1 | ED | Alte informatii
|
| > name | 1..1 | PN | Nume si prenume medic
|
| > scopingEntity | 0..1 | Entity | |
| > desc | 1..1 | ED | Denumirea institutiei medicale.
|
| > id | 0..1 | II | CUI-ul institutiei medicale.
|
Utilizari (2):
ContextObservation
ServicePerformerOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.6" |
| @typeCode | 1..1 | x_ActRelationshipExternalReference | Valoare: fixa @typeCode="XCRPT" |
| externalDocument | 1..1 | ExternalDocument | |
| > id | 1..1 | II |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.32" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29303-5" Medicamente administrate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | MedicationAdministeredOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | MedicationPrescriptionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
DeathCertificateOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.43" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="31211-6" Data decesului (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| effectiveTime | 1..1 | IVL_TS | Data decesului (@value)
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
MedicationPrescriptionOutSubstanceAdministration
MedicationAdministeredOutSubstanceAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.143" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29308-4" Diagnostic (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Descriere diagnostic
|
| value | 1..1 | CD | Diagnostic
|
Utilizari (5):
HospitalAdmissionDetailsOutObservation
ReferralDetailsOutObservation
PrescriptionDetailsOutObservation
PrimaryCareConsultationDetailsOutObservation
SpecialistConsultationDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.190" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29308-4" Diagnostic (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | DiagnosisOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (3):
HematologicDiseasesOutOrganizer
DiagnosisOutOrganizer
TransmissibleDiseasesOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.188" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29308-4" Diagnostic (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Descriere diagnostic
|
| value | 1..1 | CD | Diagnostic
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
DiagnosisOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.189" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29308-4" Diagnostic (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | DiagnosisOutObservation |
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.67" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="61144-2" Dieta (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | DietOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
DietOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.51" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="61144-2" Dieta (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
DietOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.52" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="61144-2" Dieta (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | DietOutObservation |
Utilizari (1):
HospitalAdmissionOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.209" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11535-2" Diagnostic de externare (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Descriere diagnostic
|
| value | 1..1 | CD | Diagnostic
Valoare: selectie din Set de valori ICD10AM |
Utilizari (1):
HospitalAdmissionDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.104" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="8653-8" Recomandari la externare (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Recomandari la externare
|
Utilizari (1):
DiseaseOutSection
Informatii Diagnostic
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.151" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29308-4" Diagnostic (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| effectiveTime | 1..1 | IVL_TS | Data diagnosticare (@value)
|
| value | 1..1 | CD | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / act | 0..1 | MedicationOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.74" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54140-9" Istoric boli (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | DiseasesHistorySummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
DiseasesHistorySummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.76" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54140-9" Istoric boli (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Istoric Boli/ Diagnostice
Va contine detaliile transmise de pacient cu privire la diagnosticele anterioare
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
DiseasesHistorySummaryOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.75" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54140-9" Istoric boli (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | DiseasesHistorySummaryOutObservation |
Utilizari (1):
MedicationPrescriptionOutSubstanceAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.180" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="18818-3" Cantitate eliberata (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 0..1 | IVL_TS | Durata tratament (zile) - medicament eliberat
|
| value | 1..1 | PQ | Cantitate (@value - numar, @unit="unitati")
|
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.73" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11342-3" Consum de droguri (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | DrugAddictionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
DrugAddictionOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.63" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11342-3" Consum de droguri (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
DrugAddictionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.64" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11342-3" Consum de droguri (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | DrugAddictionOutObservation |
Utilizari (2):
MedicationPrescriptionOutSubstanceAdministration
MedicationAdministeredOutSubstanceAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.142" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="18818-2" Concentratie (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| value | 1..1 | CD | Concentratia de substanta activa detinuta de medicamentul respectiv
Valoare din nomenclator - Medicamente (SIUI) - Concentratie
Valoare: selectie din Set de valori Concentrations |
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.66" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="61134-4" Mediu familial (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | FamilyEnvironmentOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
FamilyEnvironmentOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.49" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="61134-4" Mediu familial (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
FamilyEnvironmentOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.50" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="61134-4" Mediu familial (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | FamilyEnvironmentOutObservation |
Utilizari (2):
FamilyMemberPathologyOutObservation
FamilyMemberDeathReasonOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.15" |
| relatedSubject | 1..1 | RelatedSubject | |
| > code | 1..1 | CE | Membru de familie
Valoare: selectie din Set de valori FamilyMemberRelationType |
Utilizari (1):
FamilyHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.128" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54112-8" Cauza decesului membrului de familie (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | FamilyMemberDeathReasonOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
FamilyMemberDeathReasonOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.126" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54112-8" Cauza decesului membrului de familie (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| subject | 1..1 | FamilyHistorySubject | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
FamilyMemberDeathReasonOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.127" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54112-8" Cauza decesului membrului de familie (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | FamilyMemberDeathReasonOutObservation |
Utilizari (1):
FamilyHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.131" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54114-4" Patologia membrului de familie (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | FamilyMemberPathologyOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
FamilyMemberPathologyOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.129" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54114-4" Patologia membrului de familie (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| subject | 1..1 | FamilyHistorySubject | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
FamilyMemberPathologyOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.130" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="54114-4" Patologia membrului de familie (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | FamilyMemberPathologyOutObservation |
Utilizari (1):
ClinicalTrialPrescriberRole
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.150" |
| desc | 1..1 | ED | Furnizorul de Servicii Medicale unde pacientul este inregistrat in cadrul studiului - Denumire Furnizor.
|
| id | 1..1 | II | Furnizorul de Servicii Medicale unde pacientul este inregistrat in cadrul studiului - CUI Furnizor. II (@root="CUI", @extension - CUI furnizor)
|
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.215" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10172-1" Boli hematologice (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | HematologicDiseasesOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | HematologicDiseasesSummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
HematologicDiseasesAllOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.216" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10172-2" Boli hematologice diagnosticate (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | DiagnosisOutObservation |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.77" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10172-5" Boli hematologice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | HematologicDiseasesSummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
HematologicDiseasesSummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.79" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10172-5" Boli hematologice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Detalii Boli Hematologice
|
| value | 1..1 | BL | Boli Hematologice.
Campul se marcheaza daca pacientul a fost diagnosticat cu Boli Hematologice - Da/Nu
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
HematologicDiseasesSummaryOutAct
HematologicDiseasesAllOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.78" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10172-5" Boli hematologice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | HematologicDiseasesSummaryOutObservation |
Utilizari (1):
FamilyHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.134" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="32435-0" Boli ereditare (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | HereditaryDiseasesOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
HereditaryDiseasesOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.132" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="32435-0" Boli ereditare (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Boli ereditare
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
HereditaryDiseasesOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.133" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="32435-0" Boli ereditare (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | HereditaryDiseasesOutObservation |
Utilizari (1):
HospitalAdmissionDetailsOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.185" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="67852-2" Internari (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data si ora internarii (effectiveTime.low), Data si ora externarii (effectiveTime.high)
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / act | 0..1 | DiagnosisOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..2 | DischargeRecommendationsObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | MedicalSpecialityObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..1 | RelatedDocumentsOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..1 | RelatedMedicalServiceOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.207" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="34862-1" Internari (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | HospitalAdmissionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
HospitalAdmissionOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.205" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="34862-1" Internari (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data si ora internarii (effectiveTime.low), Data si ora externarii (effectiveTime.high)
|
| entryRelationship / observation | 1..* | AdmissionDiagnosisOutObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="CAUS" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 0..* | DischargeDiagnosisOutObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
HospitalAdmissionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.206" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="34862-1" Internari (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | HospitalAdmissionOutObservation |
Utilizari (1):
HospitalServiceOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.222" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29300-5" Servicii spitalicesti (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data la care serviciul este efectuat pacientului (@value - data efectuarii)
|
| value | 1..1 | CD | Codul serviciului efectuat pacientului
Valoare: selectie din Set de valori HospitalServices |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 0..1 | MedicalServiceResultAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
MedicalServicesOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.223" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29300-5" Servicii spitalicesti (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | HospitalServiceOutObservation |
Utilizari (1):
ImmunizationOutAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.71" |
| manufacturedProduct | 1..1 | ImmunizationManufacturedProduct |
Utilizari (1):
ImmunizationManufacturedProduct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.72" |
| code | 0..1 | CE | Tip vaccin.
Va contine informatii cu privire la tipul vaccinului administrat.
Valoare: selectie din Set de valori Immunizations |
| lotNumberText | 0..1 | ST | Numar lot vaccin
|
| name | 0..1 | EN | Alt antigen
|
Utilizari (1):
ImmunizationConsumable
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.73" |
| manufacturedMaterial | 1..1 | ImmunizationManufacturedMaterial |
Utilizari (1):
ImmunizationsOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.136" |
| @classCode | 1..1 | ActClass | Valoare: fixa @classCode="SBADM" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentSubstanceMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| effectiveTime | 1..1 | SXCM_TS | |
| text | 1..1 | ED | Doza administrata din respectivul vaccin
|
| consumable | 1..1 | ImmunizationConsumable | |
| entryRelationship / observation | 0..1 | AgeObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 0..1 | NationalImmunizationCalendarObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.89" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="41291-6" Imunizari (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | ImmunizationsHistorySummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ImmunizationsHistorySummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.91" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="41291-6" Imunizari (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Imunizari
Va contine detaliile transmise de pacient cu privire la imunizarile efectuate
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
ImmunizationsHistorySummaryOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.90" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="41291-6" Imunizari (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ImmunizationsHistorySummaryOutObservation |
Utilizari (1):
InsuranceInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.45" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="64291-2" Casa de asigurari (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| value | 1..1 | CD | Valoare: selectie din Set de valori InsuranceHouses |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
RelatedDocumentsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.224" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57132-1" Trimitere clinica emisa (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data trimiterii (@value - data trimiterii)
|
| id | 2..2 | II | Doua componente de identificare, reprezentand serie trimitere (@root="Serie", @extension - serie trimitere), respectiv numar trimitere (@root="Numar", @extension - numar trimitere).
|
| participant | 1..1 | SourcePhysicianParticipant | |
| entryRelationship / observation | 0..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 1..1 | MedicalSpecialityObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
RelatedDocumentsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.226" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57132-3" Recomandare pentru ingrijiri la domiciliu emisa (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data trimiterii (@value - data trimiterii)
|
| id | 2..2 | II | Doua componente de identificare, reprezentand serie trimitere (@root="Serie", @extension - serie trimitere), respectiv numar trimitere (@root="Numar", @extension - numar trimitere).
|
| participant | 1..1 | SourcePhysicianParticipant | |
| entryRelationship / observation | 0..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
RelatedDocumentsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.225" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57132-2" Trimitere paraclinica emisa (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data trimiterii (@value - data trimiterii)
|
| id | 2..2 | II | Doua componente de identificare, reprezentand serie trimitere (@root="Serie", @extension - serie trimitere), respectiv numar trimitere (@root="Numar", @extension - numar trimitere).
|
| participant | 1..1 | SourcePhysicianParticipant | |
| entryRelationship / observation | 0..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
RelatedDocumentsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.227" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57132-4" Recomandare pentru dispozitive medicale emisa (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data trimiterii (@value - data trimiterii)
|
| id | 2..2 | II | Doua componente de identificare, reprezentand serie trimitere (@root="Serie", @extension - serie trimitere), respectiv numar trimitere (@root="Numar", @extension - numar trimitere).
|
| participant | 1..1 | SourcePhysicianParticipant | |
| entryRelationship / observation | 0..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
RelatedDocumentsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.228" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="RQO" (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57828-6" Retete (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| effectiveTime | 1..1 | IVL_TS | Data (@value)
|
| id | 2..2 | II | Doua componente de identificare, reprezentand serie reteta (@root="Serie", @extension - serie reteta), respectiv numar reteta (@root="Numar", @extension - numar reteta).
|
| participant | 1..1 | Prescriber | |
| entryRelationship / observation | 0..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
AdultPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.98" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57074-7" Evolutia nasterii (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | LaborAndDeliveryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
LaborAndDeliveryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.100" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57074-7" Evolutia nasterii (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Nastere(neasistata, asistata, cezariana, evolutia nasterii sau complicatii la nastere)
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
LaborAndDeliveryOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.99" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57074-7" Evolutia nasterii (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | LaborAndDeliveryOutObservation |
Utilizari (1):
LaboratoryServiceOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.145" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Codul serviciului efectuat pacientului
Valoare: fixa @code="22032-7" Servicii paraclinice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| effectiveTime | 1..1 | IVL_TS | Data efectuarii serviciului (@value - data efectuarii)
|
| value | 1..1 | CD | Codul serviciului efectuat pacientului
Valoare: selectie din Set de valori LaboratoryServices |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 0..1 | MedicalServiceResultAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
MedicalServicesOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.146" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="22032-7" Servicii paraclinice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | LaboratoryServiceOutObservation |
Utilizari (5):
ArteriovenousFistulaProceduresOutOrganizer
ProceduresOutSection
TransplantationProceduresOutOrganizer
SurgicalProceduresOutOrganizer
ProstheticsProceduresOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.18" |
| @classCode | 1..1 | ActClass | Valoare: fixa @classCode="PROC" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentProcedureMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| effectiveTime | 1..1 | IVL_TS | Data efectuarii (@value)
|
| text | 1..1 | ED | Rezultat, Interpretare, Recomandari, Observatii
|
| code | 1..1 | CD | Procedura medicala efectuata
Valoare: selectie din Set de valori MedicalProcedures |
| > qualifier | 1..1 | CR | |
| > value | 1..1 | CD | Valoare: selectie din Set de valori MedicalProcedureTypes |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (3):
HospitalServiceOutObservation
LaboratoryServiceOutObservation
ClinicalServiceOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.163" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11313-4" Rezultat (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Rezultat / Interpretare / Recomandari / Observatii.
Va contine informatia cu privire la rezultatul sau interpretarea aferenta serviciului medical efectuat pacientului
|
| value | 0..1 | ED | Valori normale (de referinta)
|
Utilizari (5):
HospitalAdmissionDetailsOutObservation
ReferralDetailsOutObservation
IssuedClinicalReferralOutAct
SpecialistConsultationDetailsOutObservation
ReceivedClinicalReferralOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.195" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="34134-1" Specialitate medicala (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| value | 1..1 | CD | Specialitate medicala
Valoare: selectie din Set de valori MedicalSpecialities |
Utilizari (2):
CurrentMedicationOutAct
MedicationOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.34" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29303-5" Medicamente administrate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / substanceAdministration | 1..* | MedicationAdministeredOutSubstanceAdministration |
Utilizari (1):
MedicationAdministeredOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.33" |
| @classCode | 1..1 | ActClass | Valoare: fixa @classCode="SBADM" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentSubstanceMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| effectiveTime | 1..1 | SXCM_TS | Data administrarii medicamentului (@value - data administrarii)
|
| text | 1..1 | ED | Doza si intervalul de administrare pentru respectivul medicament
|
| consumable | 1..1 | MedicationConsumable | |
| entryRelationship / observation | 1..1 | ActiveSubstanceObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 1..1 | DiagnosisObservation | Diagnosticul pentru care respectivul medicament este administrat
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | DrugConcentrationObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | MedicationQuantityObservation | Va contine cantitatea totala administrata din respectivul medicament
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | PharmaceuticalFormObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (2):
MedicationPrescriptionOutSubstanceAdministration
MedicationAdministeredOutSubstanceAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.128" |
| manufacturedProduct | 1..1 | ManufacturedProduct | |
| > manufacturedLabeledDrug | 1..1 | LabeledDrug | Atunci cand denumirea comerciala a medicamentului nu este cunoscuta, elementul code nu se completeaza, iar acest element trebuie sa aiba forma <manufacturedLabeledDrug nullFlavor="UNK" />
|
| > code | 0..1 | CE | Va contine codul de medicament.
Valoare: selectie din Set de valori Drugs |
Utilizari (2):
ChronicDiseaseDetailsOutObservation
DiseaseOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.156" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="8677-7" Istoric medicamente (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | MedicationAdministeredOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | MedicationPrescriptionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PrescriptionDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.231" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="INT" (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57828-6" Retete (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / substanceAdministration | 1..* | MedicationPrescriptionOutSubstanceAdministration | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (2):
CurrentMedicationOutAct
MedicationOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.36" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="29305-0" Medicamente prescrise (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / substanceAdministration | 1..* | MedicationPrescriptionOutSubstanceAdministration |
Utilizari (2):
MedicationPrescriptionOutOrganizer
MedicationPrescriptionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.35" |
| @classCode | 1..1 | ActClass | Valoare: fixa @classCode="SBADM" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentSubstanceMood | Valoare: fixa @moodCode="RQO" (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| effectiveTime | 0..1 | SXCM_TS | Data eliberarii (@value - data eliberarii)
|
| text | 1..1 | ED | Doza si intervalul de administrare pentru respectivul medicament
|
| consumable | 1..1 | MedicationConsumable | |
| participant | 0..1 | PharmacyParticipant | Farmacia care a eliberat medicamentul
|
| entryRelationship / observation | 1..1 | ActiveSubstanceObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 1..1 | DiagnosisObservation | Diagnosticul pentru care respectivul medicament este administrat
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | DispensedQuantityObservation | Va contine cantitatea totala eliberata din respectivul medicament
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | DrugConcentrationObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | MedicationQuantityObservation | Va contine cantitatea totala prescrisa din respectivul medicament
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | PharmaceuticalFormObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (2):
MedicationPrescriptionOutSubstanceAdministration
MedicationAdministeredOutSubstanceAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.141" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="18818-1" Cantitate prescrisa (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 0..1 | IVL_TS | Durata tratament - medicamente prescrise / administrate
|
| value | 1..1 | PQ | Cantitate (@value - valoare, @unit="unitati")
|
Utilizari (1):
AdultPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.110" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42798-1" Prima menstruatie (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | MenarcheOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
MenarcheOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.112" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42798-1" Prima menstruatie (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
MenarcheOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.111" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42798-1" Prima menstruatie (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | MenarcheOutObservation |
Utilizari (1):
AdultPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.107" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42802-1" Menopauza (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | MenopauseOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
MenopauseOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.109" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42802-1" Menopauza (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
MenopauseOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.108" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42802-1" Menopauza (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | MenopauseOutObservation |
Utilizari (1):
ChronicDiseaseDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.166" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="71742-2" Data ultimei inregistrari (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| effectiveTime | 1..1 | IVL_TS | Data ultimei inregistrari (@value)
|
Utilizari (1):
ImmunizationOutAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.78" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="59779-1" Calendar national de imunizari (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | Calendar National de Imunizari
Va contine informatii cu privire la Calendarul National de Imunizari in care vaccinul curent se regaseste
|
Utilizari (1):
ChildPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.125" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42552-0" Alimentatie dupa nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | NewbornNutritionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
NewbornNutritionOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.123" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42552-0" Alimentatie dupa nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Alimentatie dupa nastere (tip, durata)
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
NewbornNutritionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.124" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="42552-0" Alimentatie dupa nastere (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | NewbornNutritionOutObservation |
Utilizari (1):
OrganDonationConsentOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.1" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| @negationInd | 0..1 | boolean | Valoare: fixa @negationInd |
| code | 1..1 | CD | Valoare: fixa @code="64300-7" Acord cu privire la donarea de organe (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
PatientConsentOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.10" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="64300-7" Acord cu privire la donarea de organe (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | OrganDonationConsentOutObservation |
Utilizari (1):
ChronicDiseaseDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.169" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="55753-8" Alte tipuri de terapii (terapii nemedicamentoase) (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | OtherTreatmentOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
OtherTreatmentOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.167" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="55753-8" Alte tipuri de terapii (terapii nemedicamentoase) (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | CD | Cod si denumire procedura sau serviciu clinic
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
OtherTreatmentOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.168" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="55753-8" Alte tipuri de terapii (terapii nemedicamentoase) (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | OtherTreatmentOutObservation |
Utilizari (2):
MedicationPrescriptionOutSubstanceAdministration
MedicationAdministeredOutSubstanceAdministration
Forma farmaceutica a medicamentului.
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.137" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52809-1" Forma farmaceutica (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | CD | Forma farmaceutica a medicamentului.
Valoare din nomenclator - Medicamente (SIUI) - Forma farmaceutica
Valoare: selectie din Set de valori PharmaceuticalForms |
Utilizari (1):
MedicationPrescriptionOutSubstanceAdministration
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.138" |
| @typeCode | 1..1 | ParticipationType | Valoare: fixa @typeCode="PRF" |
| participantRole | 1..1 | ParticipantRole | |
| > id | 1..1 | II | Identificatorul farmaciei care a eliberat (@root="CUI", @extension - CUI farmacie)
|
| > playingEntity | 1..1 | PlayingEntity | |
| > desc | 1..1 | ED | Numele farmaciei
|
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.69" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="66286-6" Exercitii fizice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | PhysicalExercisesOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PhysicalExercisesOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.55" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="66286-6" Exercitii fizice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
PhysicalExercisesOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.56" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="66286-6" Exercitii fizice (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | PhysicalExercisesOutObservation |
Utilizari (1):
PhysicianPerformer2
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.170" |
| id | 1..1 | II | Cod parafa medic (@root="Parafa", @extension - parafa medic)
|
| assignedPerson | 1..1 | AssignedPerson |
Utilizari (1):
ServicePerformerOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.169" |
| assignedEntity | 1..1 | PhysicianAssignedEntity |
Utilizari (2):
PrescriberRole
ClinicalTrialPrescriberRole
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.82" |
| name | 1..1 | PN | Numele medicului
Valoare din Registrul de Medici - Nume si Prenume
|
Utilizari (1):
AdultPhysiologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.104" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10162-6" Evolutie sarcini (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | PregnancyEvolutionOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PregnancyEvolutionOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.106" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10162-6" Evolutie sarcini (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Sarcini (evolutia sarcinii)
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
PregnancyEvolutionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.105" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="10162-6" Evolutie sarcini (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | PregnancyEvolutionOutObservation |
Utilizari (1):
IssuedMedicationPrescriptionOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.85" |
| @typeCode | 1..1 | ParticipationType | Valoare: fixa @typeCode="ATND" |
| participantRole | 1..1 | PrescriberRole |
Utilizari (1):
Prescriber
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.86" |
| id | 1..1 | II | Parafa medicului (@root="Parafa", @extension - parafa medic)
|
| playingEntity | 1..1 | PhysicianPlayingEntity |
Utilizari (1):
PrescriptionDetailsOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.197" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57828-6" Retete (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / act | 1..1 | DiagnosisOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 1..1 | MedicationPrescriptionOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PrimaryCareConsultationHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.170" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="68834-2" Consultatii MF (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data si ora consultatiei (@value)
|
| entryRelationship / observation | 0..1 | ConsultationRecommendationsObservation | Recomandari efectuate in cadrul consultatiei
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / act | 1..1 | DiagnosisOutAct | Diagnostice asociate consultatiei
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..1 | RelatedDocumentsOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..1 | RelatedMedicalServiceOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.83" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | ProceduresHistorySummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ProceduresHistorySummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.85" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | Interventii si proceduri efectuate.
Va contine detaliile transmise de pacient cu privire la procedurile efectuate anterior
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
ProceduresHistorySummaryOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.84" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ProceduresHistorySummaryOutObservation |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.19" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52051-0" Proteze, dispozitive interne (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | ProstheticsProceduresOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | ProstheticsSummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ProstheticsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.20" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / procedure | 1..* | MedicalOutProcedure |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.93" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52051-0" Proteze, dispozitive interne (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | ProstheticsSummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
ProstheticsSummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.21" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52051-0" Proteze, dispozitive interne (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Detalii Proteze si dispozitive interne
|
| value | 1..1 | BL | Proteze / dispozitive interne
Campul se marcheaza daca pacientul prezinta Proteze sau alte dispozitive interne
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
ProstheticsOutAct
ProstheticsSummaryOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.22" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="52051-0" Proteze, dispozitive interne (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ProstheticsSummaryOutObservation |
Utilizari (1):
RelatedDocumentsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.229" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57133-6" Trimitere clinica primita (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data trimiterii (@value - data trimiterii)
|
| id | 2..2 | II | Doua componente de identificare, reprezentand serie trimitere (@root="Serie", @extension - serie trimitere), respectiv numar trimitere (@root="Numar", @extension - numar trimitere).
|
| participant | 1..1 | SourcePhysicianParticipant | |
| entryRelationship / observation | 0..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / observation | 1..1 | MedicalSpecialityObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (6):
DMRClinicalDocument
EmergencySummaryOutDocument
MedicalEventsOutDocument
MedicalHistoryOutDocument
ReportedMedicalHistoryOutDocument
PatientInformationOutDocument
Informatii despre pacient
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| patientRole | 1..1 | PatientRole | |
| > id | 1..1 | II | CID-ul pacientului (@root="CID", @extension - CID-ul pacientului)
|
| > addr | 0..1 | AD | Adresa de domiciliu a pacientului
|
| > city | 1..1 | ADXP | Localitatea de domiciliu a pacientului.
Denumire din nomenclatorul de Localitati SIUI
|
| > county | 1..1 | ADXP | Judetul de domiciliu al pacientului.
Denumire din nomenclatorul de Judete SIUI
|
| > patient | 1..1 | Patient | |
| > administrativeGenderCode | 0..1 | CE | Sexul pacientului
Valoare: selectie din Set de valori AdministrativeGender |
| > birthTime | 1..1 | TS | Data nasterii
|
| > name | 1..1 | PN | Nume si prenume pacient.
|
Utilizari (1):
ReferralDetailsOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.201" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="57133-1" Trimiteri (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | CD | Tipul trimiterii
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / act | 0..1 | DiagnosisOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | MedicalSpecialityObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 0..1 | ServicePerformerOutObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (3):
HospitalAdmissionDetailsOutObservation
PrimaryCareConsultationDetailsOutObservation
SpecialistConsultationDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.230" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="67804-1" Documente asociate (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / act | 0..* | IssuedClinicalReferralOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..* | IssuedHomeCareReferralOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..* | IssuedLaboratoryReferralOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..* | IssuedMedicalDevicesReferralOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..* | IssuedMedicationPrescriptionOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..* | ReceivedClinicalReferralOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (3):
HospitalAdmissionDetailsOutObservation
PrimaryCareConsultationDetailsOutObservation
SpecialistConsultationDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.181" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / observation | 1..* | RelatedMedicalServiceOutObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
RelatedMedicalServiceOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.179" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| value | 1..1 | CD | Manevre si servicii medicale efectuate
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.68" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="28341-6" Mod de viata cu privire la odihna (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | RestOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
RestOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.53" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="28341-6" Mod de viata cu privire la odihna (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
RestOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.54" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="28341-6" Mod de viata cu privire la odihna (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | RestOutObservation |
Utilizari (1):
ResuscitationConsentOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.3" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| @negationInd | 0..1 | boolean | Valoare: fixa @negationInd |
| code | 1..1 | CD | Valoare: fixa @code="45474-5" Acord cu privire la resuscitare (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 0..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
PatientConsentOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.15" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="45474-5" Acord cu privire la resuscitare (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | ResuscitationConsentOutObservation |
Utilizari (1):
ReferralDetailsOutObservation
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.221" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11313-1" Medicul care a efectuat serviciul (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| reference | 1..1 | ContextReference | |
| performer | 1..1 | PhysicianPerformer2 |
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.71" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="72166-2" Consum de tutun (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | SmokingStatusOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
SmokingStatusOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.59" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="72166-2" Consum de tutun (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
SmokingStatusOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.60" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="72166-2" Consum de tutun (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | SmokingStatusOutObservation |
Utilizari (5):
IssuedMedicalDevicesReferralOutAct
IssuedHomeCareReferralOutAct
IssuedClinicalReferralOutAct
ReceivedClinicalReferralOutAct
IssuedLaboratoryReferralOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.10.28" |
| @typeCode | 1..1 | ParticipationType | Valoare: fixa @typeCode="REFT" |
| participantRole | 1..1 | ParticipantRole | |
| > code | 0..1 | CE | Specialitate medicala
Valoare: selectie din Set de valori MedicalSpecialities |
| > id | 1..1 | II | Cod parafa medic (@root="Parafa", @extension - parafa medic)
|
| > playingEntity | 1..1 | PlayingEntity | |
| > name | 1..1 | PN | Nume si prenume medic
|
Utilizari (1):
SpecialistConsultationHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.182" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="11488-1" Consultatii specialist (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| effectiveTime | 1..1 | IVL_TS | Data si ora consultatiei (@value)
|
| entryRelationship / observation | 0..1 | ConsultationRecommendationsObservation | Recomandari efectuate in cadrul consultatiei
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
| entryRelationship / act | 0..1 | DiagnosisOutAct | Diagnostice asociate consultatiei
Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / observation | 1..1 | MedicalSpecialityObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..1 | RelatedDocumentsOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / act | 0..1 | RelatedMedicalServiceOutAct | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.37" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="8690-0" Interventii chirurgicale recente (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | SurgicalProceduresOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
SurgicalProceduresOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.38" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="47519-4" Proceduri medicale efectuate (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / procedure | 1..* | MedicalOutProcedure |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.217" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="56838-2" Boli transmisibile (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | TransmissibleDiseasesOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | TransmissibleDiseasesSummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
TransmissibleDiseasesAllOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.218" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="56838-3" Boli transmisibile diagnosticate (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | DiagnosisOutObservation |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.80" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="56838-1" Boli transmisibile (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | TransmissibleDiseasesSummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
TransmissibleDiseasesSummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.82" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="56838-1" Boli transmisibile (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 0..1 | ED | Detalii Boli transmisibile
|
| value | 1..1 | BL | Boli Transmisibile
Campul se marcheaza daca pacientul a fost diagnosticat cu Boli Transmisibile - Da/Nu
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
TransmissibleDiseasesSummaryOutAct
TransmissibleDiseasesAllOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.81" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="56838-1" Boli transmisibile (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | TransmissibleDiseasesSummaryOutObservation |
Utilizari (1):
PersonalPathologicalHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.94" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="68849-9" Istoric transplanturi (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | TransplantationHistorySummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="GEVL" |
Utilizari (1):
TransplantationHistorySummaryOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.24" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="68849-9" Istoric transplanturi (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| text | 0..1 | ED | Detalii transplant
|
| value | 1..1 | BL | Transplantat
Campul marcheaza daca pacientul a fost Transplantat.
|
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (2):
TransplantationOutAct
TransplantationHistorySummaryOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.25" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="68849-9" Istoric transplanturi (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | TransplantationHistorySummaryOutObservation |
Utilizari (1):
EmergencyInformationOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.23" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="68849-9" Istoric transplanturi (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| entryRelationship / organizer | 0..1 | TransplantationHistorySummaryOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
| entryRelationship / organizer | 0..1 | TransplantationProceduresOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
TransplantationOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.26" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="68849-9" Istoric transplanturi (Sistem de codificare: 2.16.840.1.113883.6.1 LOINC) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / procedure | 1..* | MedicalOutProcedure |
Utilizari (1):
SocialHistoryOutSection
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.65" |
| @classCode | 1..1 | x_ActClassDocumentEntryAct | Valoare: fixa @classCode="ACT" Act (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_DocumentActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="64209-1" Conditii de munca (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| entryRelationship / organizer | 0..1 | WorkConditionsOutOrganizer | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="COMP" |
Utilizari (1):
WorkConditionsOutOrganizer
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.47" |
| @classCode | 1..1 | ActClassObservation | Valoare: fixa @classCode="OBS" Observation (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | x_ActMoodDocumentObservation | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="64209-1" Conditii de munca (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| text | 1..1 | ED | |
| entryRelationship / observation | 1..1 | ContextObservation | Elementul 'entryRelationship' contine un atribut obligatoriu 1..1: @typeCode="XCRPT" |
Utilizari (1):
WorkConditionsOutAct
| Nume | Cardinalitate | Tip de date | Documentatie |
|---|---|---|---|
| templateId | 1..1 | II | Valoare:fixa @root="2.16.840.1.113883.3.3368.11.48" |
| @classCode | 1..1 | x_ActClassDocumentEntryOrganizer | Valoare: fixa @classCode="CLUSTER" (Sistem de codificare: 2.16.840.1.113883.5.6 HL7ActClass) |
| @moodCode | 1..1 | ActMood | Valoare: fixa @moodCode="EVN" Event (Sistem de codificare: 2.16.840.1.113883.5.1001 HL7ActMood) |
| code | 1..1 | CD | Valoare: fixa @code="64209-1" Conditii de munca (Sistem de codificare: 2.16.840.1.113883.3.3368.6.26 OtherSectionCodes) |
| statusCode | 1..1 | CS | Valoare: fixa @code="completed" (Sistem de codificare: 2.16.840.1.113883.5.14 ActStatus) |
| component / observation | 1..* | WorkConditionsOutObservation |
| Sistem de codificare | Descriere | Sursa | OID |
|---|---|---|---|
| ActiveSubstances | Substante active | SIUI | 2.16.840.1.113883.3.3368.6.11 |
| AdmissionTypes | Tip internare | DES (via DRG) | 2.16.840.1.113883.3.3368.6.20 |
| BloodABO | Grupa sanguina AB0 | HL7 | 2.16.840.1.113883.3.3368.6.33 |
| BloodRh | Tip Rh | HL7 | 2.16.840.1.113883.3.3368.6.34 |
| CANAMED | Catalogul national al preturilor la medicamentele de uz uman eliberate cu prescriptie medicala, autorizate de punere pe piata | SIUI | 2.16.840.1.113883.3.3368.6.24 |
| Cities | Catalogul de localitati al SIUI | SIUI | 2.16.840.1.113883.3.3368.6.4 |
| ClinicalServices | Servicii clinice | SIUI | 2.16.840.1.113883.3.3368.6.7 |
| ClinicalServicesMF | Servicii clinice MF | SIUI | 2.16.840.1.113883.3.3368.6.43 |
| Concentrations | Concentratii medicamente | SIUI | 2.16.840.1.113883.3.3368.6.13 |
| DeathCause | Tip deces | DES (via DRG) | 2.16.840.1.113883.3.3368.6.30 |
| Diag999 | Diagnostice 999 | SIUI | 2.16.840.1.113883.3.3368.6.1 |
| DischargeStatus | Stare la externare | DES | 2.16.840.1.113883.3.3368.6.16 |
| DischargeType | Tip externare | DES | 2.16.840.1.113883.3.3368.6.19 |
| Districts | Catalogul de judete al SIUI | SIUI | 2.16.840.1.113883.3.3368.6.3 |
| DocumentTypeSources | Tipuri de documente folosite ca sursa de informatie | DES | 2.16.840.1.113883.3.3368.6.36 |
| Drugs | Nomenclator de medicamente SIUI | SIUI | 2.16.840.1.113883.3.3368.6.5 |
| FamilyMemberRelationType | Membrii de familie | HL7 | 2.16.840.1.113883.3.3368.6.25 |
| HomeCareServices | Servicii de ingrijire la domiciliu | SIUI | 2.16.840.1.113883.3.3368.6.45 |
| HospitalServices | Servicii spitalicesti | SIUI | 2.16.840.1.113883.3.3368.6.42 |
| HumanLanguage | Limba | IETF | 2.16.840.1.113883.6.121 |
| ICD10AM | Clasificarea statistica internationala a bolilor si a problemelor de sanatate inrudite, modificarile australiene (ICD-10-AM) - SIUI cim10s | SIUI | 2.16.840.1.113883.3.3368.6.18 |
| Immunizations | Imunizari | DES (via RENV) | 2.16.840.1.113883.3.3368.6.29 |
| InsuranceHouses | Case de asigurari de sanatate | SIUI | 2.16.840.1.113883.3.3368.6.35 |
| LaboratoryServices | Servicii paraclinice | SIUI | 2.16.840.1.113883.3.3368.6.8 |
| LocationType | Tip locatie pentru consultatie MF | DES | 2.16.840.1.113883.3.3368.6.21 |
| MedicalDeviceLaterality | Tipuri de dispozitive medicale | SIUI | 2.16.840.1.113883.3.3368.6.14 |
| MedicalDevices | Dispozitive medicale | SIUI | 2.16.840.1.113883.3.3368.6.2 |
| MedicalProcedureTypes | Tipuri de proceduri medicale | DES | 2.16.840.1.113883.3.3368.6.41 |
| MedicalProcedures | Proceduri medicale | SIUI | 2.16.840.1.113883.3.3368.6.17 |
| MedicalSpecialities | Specialitati medicale | SIUI | 2.16.840.1.113883.3.3368.6.9 |
| NationalHealthProgrammes | Nomenclator Programe Nationale de Sanatate | SIUI | 2.16.840.1.113883.3.3368.6.6 |
| OtherSectionCodes | Extensie LOINC | DES | 2.16.840.1.113883.3.3368.6.26 |
| PharmaceuticalForms | Forme farmaceutice | SIUI | 2.16.840.1.113883.3.3368.6.12 |
| PrescriptionTypes | Tipuri de retete | SIUI | 2.16.840.1.113883.3.3368.6.10 |
| ProsthesisTypes | Tipuri de proteze | DES | 2.16.840.1.113883.3.3368.6.15 |
| SectionTypeSources | Tipuri de sectiuni din documentele folosite ca sursa de informatie | DES | 2.16.840.1.113883.3.3368.6.37 |
| Set de valori | Sistem de codificare | Descriere | Sursa | OID |
|---|---|---|---|---|
| ActiveSubstances | ActiveSubstances 2.16.840.1.113883.3.3368.6.11 | Substante active | SIUI | 2.16.840.1.113883.3.3368.6.11.1 |
| AdministrativeGender | AdministrativeGenderCode 2.16.840.1.113883.5.1 | Sexul pacientului | HL7 | 2.16.840.1.113883.3.3368.6.40.1 |
| AdmissionTypes | AdmissionTypes 2.16.840.1.113883.3.3368.6.20 | Tip internare | DES (via DRG) | 2.16.840.1.113883.3.3368.6.20.1 |
| BloodABO | BloodABO 2.16.840.1.113883.3.3368.6.33 | Grupa sanguina AB0 | HL7 | 2.16.840.1.113883.3.3368.6.33.1 |
| BloodRh | BloodRh 2.16.840.1.113883.3.3368.6.34 | Tip Rh | HL7 | 2.16.840.1.113883.3.3368.6.34.1 |
| CANAMED | CANAMED 2.16.840.1.113883.3.3368.6.24 | Catalogul national al preturilor la medicamentele de uz uman eliberate cu prescriptie medicala, autorizate de punere pe piata | SIUI | 2.16.840.1.113883.3.3368.6.24.1 |
| Cities | Cities 2.16.840.1.113883.3.3368.6.4 | Catalogul de localitati al SIUI | SIUI | 2.16.840.1.113883.3.3368.6.4.1 |
| ClinicalServices | ClinicalServices 2.16.840.1.113883.3.3368.6.7 | Servicii clinice | SIUI | 2.16.840.1.113883.3.3368.6.7.1 |
| ClinicalServicesMF | ClinicalServicesMF 2.16.840.1.113883.3.3368.6.43 | Servicii clinice MF | SIUI | 2.16.840.1.113883.3.3368.6.43.1 |
| Concentrations | Concentrations 2.16.840.1.113883.3.3368.6.13 | Concentratii medicamente | SIUI | 2.16.840.1.113883.3.3368.6.13.1 |
| ConfidentialityCode | ConfidentialityCode 2.16.840.1.113883.5.25 | Nivel de confidentialitate | HL7 | 2.16.840.1.113883.3.3368.6.44.1 |
| DeathCause | DeathCause 2.16.840.1.113883.3.3368.6.30 | Tip deces | DES (via DRG) | 2.16.840.1.113883.3.3368.6.30.1 |
| Diag999 | Diag999 2.16.840.1.113883.3.3368.6.1 | Diagnostice 999 | SIUI | 2.16.840.1.113883.3.3368.6.1.1 |
| DischargeStatus | DischargeStatus 2.16.840.1.113883.3.3368.6.16 | Stare la externare | DES | 2.16.840.1.113883.3.3368.6.16.1 |
| DischargeType | DischargeType 2.16.840.1.113883.3.3368.6.19 | Tip externare | DES | 2.16.840.1.113883.3.3368.6.19.1 |
| Districts | Districts 2.16.840.1.113883.3.3368.6.3 | Catalogul de judete al SIUI | SIUI | 2.16.840.1.113883.3.3368.6.3.1 |
| DocumentTypeSources | DocumentTypeSources 2.16.840.1.113883.3.3368.6.36 | Tipuri de documente folosite ca sursa de informatie | DES | 2.16.840.1.113883.3.3368.6.36.1 |
| Drugs | Drugs 2.16.840.1.113883.3.3368.6.5 | Nomenclator de medicamente SIUI | SIUI | 2.16.840.1.113883.3.3368.6.5.1 |
| FamilyMemberRelationType | FamilyMemberRelationType 2.16.840.1.113883.3.3368.6.25 | Lista de relatii familiale pentru specificarea istoricului de boli familiale (4 concepte): mama naturala, tata natural, frate natural, sora naturala | HL7 | 2.16.840.1.113883.3.3368.6.25.1 |
| HomeCareServices | HomeCareServices 2.16.840.1.113883.3.3368.6.45 | Servicii de ingrijire la domiciliu | SIUI | 2.16.840.1.113883.3.3368.6.45.1 |
| HospitalServices | HospitalServices 2.16.840.1.113883.3.3368.6.42 | Servicii spitalicesti | SIUI | 2.16.840.1.113883.3.3368.6.42.1 |
| HumanLanguage | HumanLanguage 2.16.840.1.113883.6.121 | Limba | HL7 | 2.16.840.1.113883.1.11.11526 |
| ICD10AM | ICD10AM 2.16.840.1.113883.3.3368.6.18 | Clasificarea statistica internationala a bolilor si a problemelor de sanatate inrudite, modificarile australiene (ICD-10-AM) - SIUI cim10s | SIUI | 2.16.840.1.113883.3.3368.6.18.1 |
| Immunizations | Immunizations 2.16.840.1.113883.3.3368.6.29 | Imunizari | DES (via RENV) | 2.16.840.1.113883.3.3368.6.29.1 |
| InsuranceHouses | InsuranceHouses 2.16.840.1.113883.3.3368.6.35 | Case de asigurari de sanatate | SIUI | 2.16.840.1.113883.3.3368.6.35.1 |
| LaboratoryServices | LaboratoryServices 2.16.840.1.113883.3.3368.6.8 | Servicii paraclinice | SIUI | 2.16.840.1.113883.3.3368.6.8.1 |
| LocationType | LocationType 2.16.840.1.113883.3.3368.6.21 | Tip locatie pentru consultatie MF | DES | 2.16.840.1.113883.3.3368.6.21.1 |
| MedicalDeviceLaterality | MedicalDeviceLaterality 2.16.840.1.113883.3.3368.6.14 | Tipuri de dispozitive medicale | SIUI | 2.16.840.1.113883.3.3368.6.14.1 |
| MedicalDevices | MedicalDevices 2.16.840.1.113883.3.3368.6.2 | Dispozitive medicale | SIUI | 2.16.840.1.113883.3.3368.6.2.1 |
| MedicalProcedureTypes | MedicalProcedureTypes 2.16.840.1.113883.3.3368.6.41 | Tipuri de proceduri medicale | DES | 2.16.840.1.113883.3.3368.6.41.1 |
| MedicalProcedures | MedicalProcedures 2.16.840.1.113883.3.3368.6.17 | Proceduri medicale | SIUI | 2.16.840.1.113883.3.3368.6.17.1 |
| MedicalSpecialities | MedicalSpecialities 2.16.840.1.113883.3.3368.6.9 | Specialitati medicale | SIUI | 2.16.840.1.113883.3.3368.6.9.1 |
| NationalHealthProgrammes | NationalHealthProgrammes 2.16.840.1.113883.3.3368.6.6 | Nomenclator Programe Nationale de Sanatate | SIUI | 2.16.840.1.113883.3.3368.6.6.1 |
| OtherSectionCodes | OtherSectionCodes 2.16.840.1.113883.3.3368.6.26 | Extensie LOINC | DES | 2.16.840.1.113883.3.3368.6.26.1 |
| PharmaceuticalForms | PharmaceuticalForms 2.16.840.1.113883.3.3368.6.12 | Forme farmaceutice | SIUI | 2.16.840.1.113883.3.3368.6.12.1 |
| PrescriptionTypes | PrescriptionTypes 2.16.840.1.113883.3.3368.6.10 | Tipuri de retete | SIUI | 2.16.840.1.113883.3.3368.6.10.1 |
| ProsthesisTypes | ProsthesisTypes 2.16.840.1.113883.3.3368.6.15 | Tipuri de proteze | DES | 2.16.840.1.113883.3.3368.6.15.1 |
| SectionTypeSources | SectionTypeSources 2.16.840.1.113883.3.3368.6.37 | Tipuri de sectiuni din documentele folosite ca sursa de informatie | DES | 2.16.840.1.113883.3.3368.6.37.1 |