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Template Vital signs section 2007‑04‑01

Id2.16.840.1.113883.10.20.1.16Effective Date2007‑04‑01
Statuspending Under pre-publication reviewVersion Label
NameVitalSignsSectionDisplay NameVital signs section
Description

3.12 Vital Signs

The template identifier for the vital signs section is 2.16.840.1.113883.10.20.1.16.

This section contains current and historically relevant vital signs, such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, crown-to-rump length, and pulse oximetry. The section may contain all vital signs for the period of time being summarized, but at a minimum should include notable vital signs such as the most recent, maximum and/or minimum, or both, baseline, or relevant trends.

Vital signs are represented like other results (as defined in section 3.13 Results), but are aggregated into their own section in order to follow clinical conventions.

CONF-381: CCD SHOULD contain exactly one and SHALL NOT contain more than one Vital signs section (templateId 2.16.840.1.113883.10.20.1.16). The Vital signs section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more vital signs organizers (templateId 2.16.840.1.113883.10.20.1.35), each of which SHALL contain one or more result observations (templateId 2.16.840.1.113883.10.20.1.31).

3.12.1 Section conformance

CONF-382: The vital signs section SHALL contain Section / code.
CONF-383: The value for “Section / code” SHALL be “8716-3” “Vital signs” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-384: The vital signs section SHALL contain Section / title.
CONF-385: Section / titleSHOULD be valued with a case-insensitive language-insensitive text string containing “vital signs”.

3.12.2 Clinical statement conformance

The template identifier for a vital signs organizer is 2.16.840.1.113883.10.20.1.35.

Vital signs are represented like other results (as defined in section 3.13 Results), with additional vocabulary constraints.

CONF-386: A vital signs organizer (templateId 2.16.840.1.113883.10.20.1.35) SHALL be a conformant results organizer (templateId 2.16.840.1.113883.10.20.1.32).
CONF-387: A vital signs organizer SHALL contain one or more sources of information, as defined in section 5.2 Source.

ContextParent nodes of template element with id 2.16.840.1.113883.10.20.1.16
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 1 template, Uses 3 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.777.4.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.10.20.1Containmentpending CCD v1.0 Templates Root2007‑04‑01
Uses as NameVersion
2.16.840.1.113883.3.1937.777.4.10.3Containmentpending CCD Subject (Body)DYNAMIC
2.16.840.1.113883.10.20.1.35Containmentpending Vital signs organizerDYNAMIC
2.16.840.1.113883.10.20.1.40Containmentpending CommentDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 (2005‑09‑07)
ItemDTCardConfDescriptionLabel
hl7:section
Vitadotstion
@classCode
cs0 … 1 
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.20215 ActClassDocumentSection (DYNAMIC)
@moodCode
cs0 … 1 
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.1.11.20267 ActMoodEventOccurrence (DYNAMIC)
hl7:templateId
II1 … 1Vitadotstion
@root
uid1 … 1F2.16.840.1.113883.10.20.1.16
hl7:id
II0 … 1Vitadotstion
hl7:code
CE1 … 1MCONF‑382 / CONF‑383
@code
CONF1 … 1F8716-3
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MCONF‑384 / CONF‑385
 Schematron assertrolered error 
 testcontains(lower-case(.),'vital signs') 
 MessageCONF-385: Section / title SHOULD be valued with a case-insensitive language-insensitive text string containing “vital signs”. 
hl7:text
SD.TEXT1 … 1RCONF‑381
hl7:confidentialityCode
CE0 … 1Vitadotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16926 x_BasicConfidentialityKind (DYNAMIC)
hl7:languageCode
CS0 … 1Vitadotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:subject
0 … 1Contains 2.16.840.1.113883.3.1937.777.4.10.3 CCD Subject (Body) (DYNAMIC)Vitadotstion
hl7:entry
1 … *Contains 2.16.840.1.113883.10.20.1.35 Vital signs organizer (DYNAMIC)CONF‑381
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
@contextConductionInd
bl0 … 1 
hl7:entry
0 … *Contains 2.16.840.1.113883.10.20.1.40 Comment (DYNAMIC)CONF‑502
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19446 x_ActRelationshipEntry (DYNAMIC)
@contextConductionInd
bl0 … 1