| Level/Type | Code | Display Name | | | | Codesystem | | | | Description |
|
|
| 0-L | 10160-0 | History of medication use | | | | 2.16.840.1.113883.6.1 | | | | The medications section shall contain a description of the relevant medications for the patient, e.g. an ambulatory prescription list. It shall include entries for medications as described in the Entry Content Module. All prescribed medicine whose period of time indicated for the treatment has not yet expired whether it has been dispensed or not. |
|
| 0-L | 10162-6 | | | | | 2.16.840.1.113883.6.1 | | | | |
|
| 0-L | 10164-2 | History of present illness | | | | 2.16.840.1.113883.6.1 | | | | The history of present illness section shall contain a description of the sequence of events preceding the patient’s current complaints. Step by step description of ethiopathogenesis of current problem patient is being treated for. |
|
| 0-L | 11348-0 | | | | | 2.16.840.1.113883.6.1 | | | | The History of Past Illness section shall contain a description of the conditions the patient suffered in the past. It shall include entries for problems as described in the Entry Content Modules. Illness which set on and resolved in the past. |
|
| 0-L | 11369-6 | | | | | 2.16.840.1.113883.6.1 | | | | The immunizations section shall contain a description of the immunizations administered to the patient in the past. It shall include entries for medication administration as described in the Entry Content Modules. Active immunizations received in the past. |
|
| 0-L | 11450-4 | | | | | 2.16.840.1.113883.6.1 | | | | The active problem section shall contain a description of the conditions currently being monitored for the patient. It shall include entries for patient conditions as described in the Entry Content Module. Chronic, recurring or persistent illnesses, requiring repeated reassessment and/or continuos/periodic therapy. |
|
| 0-L | 18776-5 | | | | | 2.16.840.1.113883.6.1 | | | | The care plan section shall contain a description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. Therapeutic recommendations that do not include drugs |
|
| 0-L | 29554-3 | | | | | 2.16.840.1.113883.6.1 | | | | The procedure entry is used to record procedures that have occurred, or which are planned for in the future. |
|
| 0-L | 29762-2 | | | | | 2.16.840.1.113883.6.1 | | | | |
|
| 0-L | 30954-2 | Relevant diagnostic tests/laboratory data | | | | 2.16.840.1.113883.6.1 | | | | |
|
| 0-L | 46264-8 | History of medical device use | | | | 2.16.840.1.113883.6.1 | | | | The medical devices section contains text describing the patient history of medical device use. Documented necessity to use a device replacing/supporting completely/partially a body organ/organ system function. |
|
| 0-L | 47420-5 | Functional status assessment | | | | 2.16.840.1.113883.6.1 | | | | The Coded Functional Status Assessment Section provided a machine readable and description of the patient’s status of normal functioning at the time the document was created. Pain Scale Assessment, Braden Score Assessment, and Geriatric Depression Scale are subsections of the Functional Status Assessment Section |
|
| 0-L | 47519-4 | | | | | 2.16.840.1.113883.6.1 | | | | The list of surgeries section shall include entries for procedures and references to procedure reports when known as described in the Entry Content Modules. Surgical or other invasive procedures in the past, on vital organs/body cavities/vascular or central nervous system. |
|
| 0-L | 48765-2 | Allergies, adverse reactions, alerts | | | | 2.16.840.1.113883.6.1 | | | | The adverse and other adverse reactions section shall contain a description of the substance intolerances and the associated adverse reactions suffered by the patient. It shall include entries for intolerances and adverse reactions as described in the Entry Content Modules Presence/absence of potentially life threatening reaction to substances/factors, to which patient can be exposed in the environment, or during treatment, of allergic or other known nature. |
|
| 0-L | 57828-6 | | | | | 2.16.840.1.113883.6.1 | | | | |
|
| 0-L | 60590-7 | | | | | 2.16.840.1.113883.6.1 | | | | |
|
| 0-L | 8716-3 | | | | | 2.16.840.1.113883.6.1 | | | | The vital signs section contains coded measurement results of a patient’s vital signs. |
|