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.