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draft Template  Anamnesi Fisiologica-Patologica (RSA)

Id 2.16.840.1.113883.3.1937.777.63.10.375 Effective Date 2023‑12‑18 10:23:24
Status draft Draft Version Label AFP(RSA)
Name AFP Display Name Anamnesi Fisiologica-Patologica (RSA)
Description en-US Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)
Context Parent nodes of template element with id 2.16.840.1.113883.3.1937.777.63.10.375
Label ObservationAnamnesiFis‑Pat(RSA)
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 2 templates, Uses 2 templates
Used by as Name Version
2.16.840.1.113883.2.9.10.1.9.3.2 Containment draft Storia Clinica (RSA) 2018‑04‑11
2.16.840.1.113883.2.9.10.1.9.1 link draft Referto di Specialistica Ambulatoriale (RSA) 2018‑04‑11
Uses as Name Version
2.16.840.1.113883.3.1937.777.63.10.136 Containment draft Cronicità DYNAMIC
2.16.840.1.113883.3.1937.777.63.10.137 Containment draft Stato DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.3.1937.777.63.10.316 Anamnesi Fisiologica-Patologica (VPS) (2023‑05‑03 19:52:54)
Specialization: template 2.16.840.1.113883.3.1937.777.63.10.135 Anamnesi Fisiologica-Patologica (RAP) (2022‑09‑21 13:54:39)
Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Item DT Card Conf Description Label
hl7:observation
1 … 1 R en-US

Elemento che riporta tutte le informazioni dettagliate relative all’anamnesi patologica prossima, patologica remota e anamnesi fisiologica.

ObsedotsRSA)
@classCode
cs 1 … 1 F OBS
@moodCode
cs 1 … 1 F EVN
hl7:templateId
II 0 … 1 R ObsedotsRSA)
@root
uid 1 … 1 F 2.16.840.1.113883.3.1937.777.63.10.375
hl7:code
CD 1 … 1 R ObsedotsRSA)
@code
cs 1 … 1 F 75326-9
@codeSystem
uid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
st 0 … 1 F LOINC
@displayName
st 0 … 1   en-US

Problem

  Example <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>
hl7:text
ED 0 … 1 ObsedotsRSA)
hl7:statusCode
CS 1 … 1 R ObsedotsRSA)
@code
CONF 0 … 1 F completed
hl7:effectiveTime
IVL_TS 1 … 1 R en-US

E' un elemento che distingue, attraverso un riferimento temporale, l’anamnesi patologica prossima dall’anamnesi patologica remota.

ObsedotsRSA)
  Example <effectiveTime>
  <low value="[DT_PRIMA_INSORG]"/>  <high value="[DT_ULTIMA_INSORG]"/></effectiveTime>
hl7:value
CD 1 … 1 M en-US

L'elemento può essere codificato od essere una stringa non codificata, in ogni caso il tipo di tale elemento deve essere sempre un valore codificato (xsi:type='CD').

ObsedotsRSA)
  Example
Esempio 1: value codificato
<value type="CD" code="60975-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Resistenza Vascolare"/>
  Example
Esempio 2: value non codificato
<value type="CD">
  <originalText>
    <reference value="#value_as_text"/>  </originalText>
</value>
hl7:entryRelationship
0 … 1 Contains 2.16.840.1.113883.3.1937.777.63.10.136 Cronicità (DYNAMIC) ObsedotsRSA)
@typeCode
cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19447 x_ActRelationshipEntryRelationship (DYNAMIC)
hl7:entryRelationship
0 … 1 Contains 2.16.840.1.113883.3.1937.777.63.10.137 Stato (DYNAMIC) ObsedotsRSA)
@typeCode
cs 1 … 1 R
  CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19447 x_ActRelationshipEntryRelationship (DYNAMIC)