Id2.16.840.1.113883.3.1937.99.61.5.10.900282Gültigkeit ab2014‑07‑29 11:35:31
Statusdraft EntwurfVersions-Label
NameHistoryofPresentIllnessBezeichnungHistory of Present Illness Section
Beschreibung
This (sub)section describes the history of present illness
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.3.1937.99.61.5.10.900282
KlassifikationCDA Section level template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 1 Transaction und 2 Templates, Benutzt 0 Templates
Benutzt von als NameVersion
2.16.840.1.113883.3.1937.99.61.5.4.22Transaktiondraft CDA Document APSR22014‑11‑16 11:45:10
2.16.840.1.113883.3.1937.99.61.5.10.900273linkdraft Anatomic Pathology Structured Report2014‑05‑13 11:57:57
2.16.840.1.113883.3.1937.99.61.5.10.900275Inklusiondraft APSR2 Clinical Information Section2014‑05‑13 14:38:08
BeziehungSpezialisierung: Template 1.3.6.1.4.1.19376.1.5.3.1.3.4 (2012‑06‑01)
Beispiel
Beispiel
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.2.11.10.103"/>  <code code="10164-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Present Illness"/>  <title>History of present illness</title>  <text>Carcinoma of breast. Post operative diagnosis: same. Left UOQ breast mass.</text></section>
Beispiel
Original C-CDA example
<section>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>  <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="10164-2" displayName="HISTORY OF PRESENT ILLNESS"/>  <title>HISTORY OF PRESENT ILLNESS</title>  <text>
    <paragraph>This patient was only recently discharged for a recurrent
GI bleed as described below.</paragraph>    <paragraph>He presented to the ER today c/o a dark stool yesterday
but a normal brown stool today. On exam he was hypotensive in the
80s resolved after .... .... .... </paragraph>    <paragraph>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1,
electrolytes normal. H. pylori antibody pending. Admission
hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet
count 256,000. Urinalysis normal. Urine culture: No growth. INR
1.1, PTT 40.</paragraph>    <paragraph>He was transfused with 6 units of packed red blood cells
with .... .... ....</paragraph>    <paragraph>GI evaluation 12 September: Colonoscopy showed single red
clot in .... .... ....</paragraph>  </text></section>
ItemDTKardKonfBeschreibungLabel
hl7:section
0 … *Histdotsness
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RHistdotsness
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.3.4
hl7:templateId
II1 … 1MHistdotsness
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900282
hl7:code
CD1 … 1MHistdotsness
@code
CONF1 … 1F10164-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MHistdotsness
 Beispiel<title> History of present illness </title>
hl7:text
SD.TEXT1 … 1MHistdotsness
 Beispiel<text>Carcinoma of breast. Post operative diagnosis: same. Left UOQ breast mass. </text>