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active Template  Anamnesi (VPS)

Id 2.16.840.1.113883.2.9.10.1.6.55 Effective Date 2018‑03‑19
Status active Active Version Label VPS
Name AnamnesiVPS Display Name Anamnesi (VPS)
Description en-US History General (LOINC: 11329-0)
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 2 templates, Uses 3 templates
Used by as Name Version
2.16.840.1.113883.2.9.10.1.6.56 Containment active Inquadramento clinico iniziale (VPS) (VPS) 2018‑03‑19
2.16.840.1.113883.2.9.10.1.6.1 link active Verbale di Pronto Soccorso (VPS) 2023‑05‑17 12:00:45
Uses as Name Version
2.16.840.1.113883.3.1937.777.63.10.318 Containment active assignedAuthor_BodyVPS (VPS) DYNAMIC
2.16.840.1.113883.3.1937.777.63.10.316 Containment active Anamnesi Fisiologica-Patologica (VPS) (VPS) 2023‑05‑03 19:52:54
2.16.840.1.113883.3.1937.777.63.10.317 Containment active Anamnesi Familiare (VPS) (VPS) 2023‑05‑03 20:06:14
Relationship Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Item DT Card Conf Description Label
hl7:section
 		1 … 1 R
@classCode
 		cs 0 … 1 F DOCSECT
@moodCode
 		cs 0 … 1 F EVN
hl7:templateId
 		II 1 … 1 R
@root
 		uid 1 … 1 F 2.16.840.1.113883.2.9.10.1.6.55
hl7:id
 		II 0 … 1
hl7:code
 		CE 1 … 1 R
@code
 		cs 1 … 1 F 11329-0
@codeSystem
 		oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
 		st 0 … 1 F LOINC
@displayName
 		st 0 … 1 F Anamnesi Generale
hl7:title
 		ST 0 … 1
  CONF
element content SHALL be "Anamnesi"
hl7:text
 		SD.TEXT 1 … 1 R Blocco human readable: Note dell’anamnesi
hl7:author
 		0 … * Include nome, cognome e codice fiscale dell’operatore autore dell’anamnesi
hl7:time
 		TS 1 … 1 R Data e ora dell’anamnesi
hl7:assignedAuthor
 		1 … 1 R Contains 2.16.840.1.113883.3.1937.777.63.10.318 assignedAuthor_BodyVPS (DYNAMIC)
hl7:entry
 		0 … 1

Elemento OPZIONALE atto a riportare le informazioni dettagliate relative all’anamnesi patologica prossima, patologica remota e all’anamnesi fisiologica.


Contains 2.16.840.1.113883.3.1937.777.63.10.316 Anamnesi Fisiologica-Patologica (VPS) (2023‑05‑03 19:52:54)
@typeCode
 		cs 1 … 1 F COMP
  Example <observation moodCode="EVN" classCode="OBS">
  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20220410101010+0100"/>    <high value="20220420101010+0100"/>  </effectiveTime>  <value code="153.5" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9-CM" displayName="TUMORI MALIGNI DELL'APPENDICE"/>  <entryRelationship typeCode="REFR" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <code code="89261-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Decorso Clinico"/>      <text>
        <reference value="#[REF_CRON]"/>      </text>      <statusCode code="completed"/>      <value code="LA28752-6" codeSystem="2.16.840.1.113883.6.1" displayName="Chronic"/>    </observation>  </entryRelationship>  <entryRelationship typeCode="REFR" inversionInd="false">
    <observation classCode="OBS" moodCode="EVN">
      <code code="33999-4" displayName="Stato" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>      <text>
        <reference value="#[REF_STATO]"/>      </text>      <statusCode code="completed"/>      <value code="LA16666-2" codeSystem="2.16.840.1.113883.6.1" displayName="Active"/>    </observation>  </entryRelationship></observation>
hl7:entry
 		0 … *

Elemento OPZIONALE atto a raccogliere tutte le informazioni relative all’anamnesi familiare.


Contains 2.16.840.1.113883.3.1937.777.63.10.317 Anamnesi Familiare (VPS) (2023‑05‑03 20:06:14)
@typeCode
 		cs 1 … 1 F COMP
  Example <organizer classCode="CLUSTER" moodCode="EVN">
  <code code="10157-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Storia di malattie di membri familiari"/>  <statusCode code="completed"/>  <effectiveTime value="20220423101010+0100"/>  <subject typeCode="SBJ">
    <relatedSubject classCode="PRS">
      <code code="MTH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="RoleCode" displayName="Mother"/>      <subject>
        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" codeSystemName="HL7 AdministrativeGender" displayName="Femmina"/>      </subject>    </relatedSubject>  </subject>  <component>
    <observation classCode="OBS" moodCode="EVN">
      <code code="52797-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosi codice ICD"/>      <text>
        <reference value="#[REF_OBS]"/>      </text>      <statusCode code="completed"/>      <effectiveTime value="20220410101010+0100"/>      <value code="575.6" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9-CM" displayName="COLESTEROLOSI DELLA COLECISTI"/>      <entryRelationship typeCode="SUBJ">
        <observation classCode="OBS" moodCode="EVN">
          <code code="35267-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Età diagnosi patologia"/>          <value value="40" unit="a"/>        </observation>      </entryRelationship>      <entryRelationship typeCode="SUBJ">
        <observation classCode="OBS" moodCode="EVN">
          <code code="39016-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Età_decesso"/>          <value value="70" unit="a"/>        </observation>      </entryRelationship>    </observation>  </component></organizer>