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draft Template  Anamnesi Fisiologica-Patologica (RAP)

Id 2.16.840.1.113883.3.1937.777.63.10.135 Effective Date 2022‑09‑21 13:54:39
Status draft Draft Version Label AFP
Name AFP Display Name Anamnesi Fisiologica-Patologica (RAP)
Description en-US Template CDA Observation (prototype, directly derived from POCD_RM000040 MIF)
Context Parent nodes of template element with id 2.16.840.1.113883.3.1937.777.63.10.135
Label ObservationAnamnesiFis‑Pat(RAP)
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 2 templates
Used by as Name Version
2.16.840.1.113883.3.1937.777.63.10.282 Containment draft Anamnesi 2023‑01‑26 10:32:47
2.16.840.1.113883.3.1937.777.63.10.132 link draft Notizie Cliniche (RAP) (notizieClinicheRAP) 2022‑09‑21 12:45:29
2.16.840.1.113883.2.9.10.1.8.1 link draft Referto di Anatomia Patologica (RAP) (Referto di Anatomia Patologica (RAP)) 2022‑09‑20 14:53:37
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 2.16.840.1.113883.10.12.303 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.

ObsedotsRAP)
@classCode
cs 0 … 1 F OBS
@moodCode
cs 1 … 1 F EVN
hl7:templateId
II 1 … 1 M ObsedotsRAP)
@root
uid 1 … 1 F 2.16.840.1.113883.3.1937.777.63.10.135
hl7:code
CD 1 … 1 R ObsedotsRAP)
@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 ObsedotsRAP)
hl7:statusCode
CS 1 … 1 R ObsedotsRAP)
@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.

ObsedotsRAP)
  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').

ObsedotsRAP)
  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) ObsedotsRAP)
@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) ObsedotsRAP)
@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)