<p>This is a computer translation of the original webpage. It is provided for general information only and should not be regarded as complete nor accurate. Source Language: French Target Language: English Have this document professionally translated for only: $31,712.00 USD* </p><p>Country of the Loire</p><p>STRUCTURING IN HALF-VALUE LAYER OF THE DOCUMENT “GENERAL AND PREVIOUS INFORMATION " OF THE PERINATALITY FIELD </p><p>Version 1.21 CARD-INDEX OF UPDATE Approval Name/ Function/Visa/Date</p><p>@ file :: odma \ pcdocs \ docsopen \ 119141 \ 2 Nb pages 8784 @ model \ \ abyssal zone \ quality \ sq \ MOD \ cabestan_commun \ Doc.-15-document generiquenewlogo.dot Diffusion Intern</p><p>External</p><p>Version Writer Date Comment Chapter Origin 1.0 I Gibaud 09/10/07 Creation of the document *</p><p>1.1 I Gibaud 28/01/08 Code Loinc SPOKE Use of a local nomenclature to code the antecedents gyneco-obstetrics Family antecedents relating to the family of the father and the family of the mother: use of code FAMMEMB Correction of the ex of the section “current alcohol/substance misuses”</p><p>1.2 I Gibaud 11/03/08  Correction of the example “family history section”: modif of the templateId according to spec  Section “history off tobacco uses” (table) : in the connection with the episode, to replace statusCode by code subject participation: to replace “section by observation  Section “current alcohol” Subject participation: to replace relationShip by entryRelationShip SYNOPSIS</p><p>1. DESCRIPTION OF AT THE HEAD OF THE DOCUMENT ...... 4</p><p>1.1 CLINICALDOCUMENT ...... 4 1.2 TYPEID ...... 5 1.3 TEMPLATEID...... 5 1.4 ID...... 5 1.5 CODE...... 6 1.6 EFFECTIVETIME...... 6 1.7 CONFIDENTIALITYCODE...... 7 1.8 RECORDTARGET...... 7 1.9 AUTHOR...... 8 1.10 CUSTODIAN...... 8 1.11 AUTHORIZATION/AUTHORIZES ...... 9 2. DESCRIPTION OF THE BODY OF THE DOCUMENTS OF THE PERINATALITY FIELD ...... 11</p><p>2.1 STRUCTURING OF LEVEL 2: SECTIONS ...... 11 2.1.1 namespaces and vocabularies ...... 11 2.1.2 Owners of identifiers of documents ...... 11 2.1.3 style sheets ...... 12 2.1.4 The model general of a section ...... 12 2.2 STRUCTURING OF LEVEL 3: ENTRIES ...... 14 2.2.1 Entries of level 3 dedicated to the multi-media posting of information ...... 14 2.2.2 Entries of level 3 dedicated to the exploittation of the structured data: ...... 14 2.3 SPECIFICATION OF THE DOCUMENT “GENERAL INFORMATION AND ANTECEDENTS” ...... 1 2.3.1 structuring of level 2: list sections of the document ...... 1 2.3.2 structuring of level 3: the structured part ...... 3 2.3.3 personal antecedents 11322-5 ...... 21 2.3.4 Medical antecedents (11348-0) ...... 21 2.3.5 surgical antecedents 47519-4 ...... 32 2.3.6 gynéco-obstétricaux antecedents 11449-6 ...... 35 2.3.7 Family antecedents 10157-6 ...... 39 2.3.8 other antecedents 10157-6 ...... 46 2.3.9 Addiction with the tobacco (History off Tobacco uses) 11366-2 ...... 49 2.3.10 Addiction with alcohol and other substances (Current Alcohol/substance misuses) 18663-5 ...... 55 2.3.11 Immunizations 11369-6 ...... 61 This note aims to describe the structuring of the principal documents used within the network of health birth (RSN) of the countries of the Loire. This study relates initially to a restricted number of documents. It will be then generalized with the whole of the documents used by the RSN. The SIB proposes to retain the standard HALF-VALUE LAYER r2[1] of HL7v3 to describe the structuring of these documents. The first paragraph of this note briefly points out the general structure of a document HALF-VALUE LAYER. The following paragraphs describe at the head document HALF-VALUE LAYER which is identical some is the document. The body of the document is then described, it varies according to the nature of the document.</p><p>1. DESCRIPTION OF AT THE HEAD OF THE DOCUMENT This section of this document describes in head HALF-VALUE LAYER of a document of perinatality. It refers to the French specification of the metadata of documents CDAr2 (Header) written by HL7-France. All the implementations HALF-VALUE LAYER apply various restrictions and/or constraints compared to the specifications required by the standard. For example, certain implementations retain only the strictly necessary metadata by the standard, others will make compulsory the seizure of one or two metadata not strictly required by the standard. Thus, the majority of the pressures applied to this level correspond to those which are defined in the document of French specifications of the metadata associated with the header[2]. At the head of the document HALF-VALUE LAYER describes the context in which the document is produced. It consists of a whole of metadata which identifies the patient, the meeting between the doctor and the patient who gave place to this document, the list of the participants related to the activity practised during this meeting (author, writer, assentor, etc). The specification HALF-VALUE LAYER in itself ensures that the whole of this information must be able to be posted and to be readable for any user entitled to open the document, in a joint way with the body of the document, using a simple navigator. The posting of the body of the private document of the posting of at the head does not have a direction. In other words, at the head of the document body of the document is indissociable. General constraints on the people and the organizations For each person mentioned in the document, will be specified the name, the address and the telephone co-ordinates of the person.</p><p>1.1 CLINICALDOCUMENT The root of a document HALF-VALUE LAYER is obligatorily a ClinicalDocument element of the space of naming urn: hl7-org: v3. Example: <ClinicalDocument xmlns= "urn: hl7-org: v3“xmlns: xsi=”http://www.w3.org/2001/XMLSchema-instance“ xsi: schemaLocation= "urn: hl7-org: v3 CDA.xsd“></p><p>1.2 TYPEID Obligatory attribute. the type of identifier is a reference to the specification HALF-VALUE LAYER r2. This element is composed of two attributes: - the root (root) which has as a value “2.16.840.1.113883.1.3” (OID of recording of models HL7). - The extension which has as a value “POCD_HD000040” which corresponds to the single identifier of the CDAr2 specification. Example: <typeId root="2.16.840.1.113883.1.3“ extension="POCD_HD000040“/> This element must obligatorily appear in an authority of document HALF-VALUE LAYER.</p><p>1.3 TEMPLATEID The CDAr2 documents in conformity with the guide of implementation present will indicate their conformity by the inclusion of the suitable element following TemplateId: <templateId root=” 1.3.6.1 .4.1.19376.1.5.3.1.1.2” extension= “medical summary “ In addition to this template, for each document of the field of perinatality described, one will use a templateId corresponding. For example, the document of general and previous information will be in conformity with the model of medical summary. The document of summary of pregnancy will be in conformity with the model “antepartum summary”.</p><p>1.4 ID Obligatory attribute. The element “id” represents the single identifier of authority of the clinical document (UID). This UID identifies in a universal way this document, so that it can be divided and/or exchanged between various systems without there being collision risk of identifiers coming from the various systems. The element id consists of a root and an extension. Example: <id root= "2.16.840.1.113883.19.4“ extension= "c266“/> The root of identification within the framework of the documents produced for the RSN remains to be determined. Each medical document specified within the framework of the field of perinatality will be equipped with single Id.</p><p>1.5 CODE Obligatory attribute. The element code specifies the kind of the document such as a summary of exit, a report of consultation, synthesis of episode, etc The whole of the possible values carcatérisant the kind of the document results from nomenclature LOÏNC. The attributes necessary for this elements are it code and it codesystem. The code specifies the kind of the document coded by LOÏNC and the codesystem corresponds to the OID of organization LOÏNC. Attributes codeSystemName and displayName are optional and can be well informed at ends of legibility by the user. The codeSystemName must then take value “LOINC” and the displayName corresponds to the wording of the code like document within nomenclature LOINC. Examples: If the document is a note of consultation: <code code= "11488-4“ codeSystem= "2.16.840.1.113883.6.1" codeSystemName= " LOINC " displayName= " Consultation notes "/> If the document is a summary of episode: <code code= "34133-9“codeSystem=”2.16.840.1.113883.6.1" codeSystemName= " LOINC " displayName= " Summarization off Episode notes "/></p><p>1.6 EFFECTIVETIME Obligatory attribute. This element corresponds to the effective creation date of the document by the system of origin. If a new version comes to replace the current version, effectiveTime corresponds to the creation date of the new version. Examples: Interpreted like year/month/day/heure/mn/sec in the standard time, <effectiveTime value= "20050329224411“/> Interpreted like year/month/day/heure/mn/sec with declaration of a shift compared to meridian line zero. <effectiveTime value= "20050329224411-0600“/> Interpreted like year/month/day/hour in the standard time, <effectiveTime value= "2005032922“/></p><p>1.7 CONFIDENTIALITYCODE Obligatory attribute. The Confidentiality element is necessary as a contextual element of a document HALF-VALUE LAYER. It expresses the level of confidentiality of the document. Examples: Normal confidentiality <confidentialityCode code= "NR“codeSystem=”2.16.840.1.113883.5.25“/> Reduced confidentiality <confidentialityCode code= "R“codeSystem=”2.16.840.1.113883.5.25“/> Very reduced confidentiality <confidentialityCode code= "V“codeSystem=”2.16.840.1.113883.5.25“/></p><p>1.8 RECORDTARGET Obligatory attribute. The element recordTarget carry the data elements concerning the subject for which this document was carried out. In the majority of the cases, a clinical document is connected to only one recordTarget. However it is possible to associate several recordTarget a document in the case for example where this one concerns at the same time the mother and her child or in the case of a document concerning a whole of patients (of the twins for example). Example: In the following example, the root and extionsion off the id patient are supplied by the orgnization that is defining. The patient and its child name element, while optional per the diagram, may Be required by has business rule for has sensitive record to Be created. This is also true for the providerOrganization element and its children. <recordTarget> <patientRole> <id extension= "12345“ root= "2.16.840.1.113883.19.5“/> <patient> <name> <given>Henry</given> <family>Levin</family> </name> <administrativeGenderCode code= "M" codeSystem= "2.16.840.1.113883.5.1"/> <birthTime value= "19320924"/> </patient> <providerOrganization> <id root= "2.16.840.1.113883.19.5"/> <name>Organization Name</name> </providerOrganization> </patientRole> </recordTarget></p><p>1.9 AUTHOR Obligatory attribute. the element author represent the person or the system author of the clinical document. The elements wire time and assignedAuthor are necessary. It can exist several authors of the same document. If the whole of these actors endorses the responsibility for author of the totality of the document, it is necessary to reveal as many elements author that there are actors. If each actor endorses the responsibility for author of part of the document, it is necessary to reveal the element author on the level of the section concerned. In this case, the author attached to the section supplants the author declared on the level of at the head. Example: <author> <time value= "200601101245“/> <assignedAuthor> <id extension= "0014“ root= "2.16.840.1.113883.19.5“/> <addr> <streetAdressLine>2 street of the fir trees</streetAdressLine> <city>Rennes</city> <postalCode>35000</postalCode> <country>France</country> </addr> <telecom value= `such: 0999246753' use=' DIR'/> <assignedPerson> <name> <given>Robert</given> <family>Dolin</family> <suffix>MANDELEVIUM</suffix> </name> </assignedPerson> <representedOrganization> <id root= "2.16.840.1.113883.19.5"/> <name>Organization Name</name> </representedOrganization> </assignedAuthor> </author></p><p>1.10 CUSTODIAN Obligatory attribute. The element custodian represent the organization which has in responsibility of manage the clinical document, it acts of the structure which produced this document. This organization is described in the element custodian/assignedCustodian/representedCustodianOraganization made up of under following obligatory elements: Id: single identifier of the organization, Name: name of this organization Addr: adrress Telecom: telephone co-ordinates. Example: <custodian> <assignedCustodian> <representedCustodianOrganization> <id root= "2.16.840.1.113883.19.5“/> <name>Organization Name</name> <addr> <streetAdressLine>2 street of the pines</streetAdressLine> <city>Rennes</city> <postalCode>35000</postalCode> <country>France</country> </addr> <telecom value= `such: 099925794' use=' DIR'/> </representedCustodianOrganization> </assignedCustodian> </custodian></p><p>1.11 AUTHORIZATION/AGREES Optional attribute. The value of the code assent translates the enabling granted a functional role on a resource. For example, a user who intervenes as a member of the medical team of maternity has the right to consult the report of childbirth. The crossing between the functional role “equips medical” and “report of childbirth” results in a code assent determined by the medical community and which corresponds to the right of reading of this document. Thus, the whole of enablings necessary to the operation of the network will have to be determined by the medical community in coherence with the decrees of application fixed by the law and in coherence with the great national projects such as the DMP-child. <authorization typeCode=' AUTH'> <classCode=' CONS' moodCode=' EVN' agrees> <id root='identifier root of the policy of safety accepted by the patient' extension=“extension of the identifier”/> <code code=“code of the policy” codeSystem= '' codeSystemName= '' displayName= ''/> <statusCode code=' completed'/> </consent> </authorization> 2. DESCRIPTION OF THE BODY OF THE DOCUMENTS OF THE PERINATALITY FIELD The description of the various documents below is inspired of work resulting from association HL7-France, thus that of various work of implementation of the HALF-VALUE LAYER which exists: [I] HL7 Implementation Guides: HALF-VALUE LAYER Release 2-Continuity off Care Document (CCC) (April 01,2007) [2] Patient IHE Care Coordination Technical framework vol1 and 2 (August 15, 2007) The whole of the documents HALF-VALUE LAYER described are likely to be generated starting from the files trades of speciality lodged in the establishments of health which deal with the patient, like starting from the files of network of perinatality placed at the disposal of the doctors liberal and lodged by a third. Network RSN of the countries of the Loire wishes to evaluate the activity of the network. For this reason, it is necessary to propose a structuring HALF- VALUE LAYER of level 3 of the documents. It remains nevertheless to determine the level of structuring wished for each document of the perinatality field. The body of the document breaks up into sections (level 2) which contain: - a block of text describing the elements of page-setting of information readable by the user by means of a navigator, - one or more entries (level 3 or entries) which correspond to the coded part of the data listed and posted by the block text.</p><p>2.1 STRUCTURING OF LEVEL 2: SECTIONS</p><p>2.1.1 NAMESPACES AND VOCABULARIES This section lists the namespaces and the identifiers used in this document as well as the systems of coding used. codeSystem codeSystemName Description 2.16.840.1.113883.6.96 SNOMED-CT SNOMED Controlled Terminology 2.16.840.1.113883.6.1 LOINC 2.16.840.1.113883.6.3 CIM10 Codes systems specific to the DPERINAT-RSN field of the perinatality in France: to define</p><p>2.1.2 OWNERS OF IDENTIFIERS OF DOCUMENTS HALF-VALUE LAYER is a generic standard of document. This standard cannot be implemented without passing by the writing of “templates ” (guides of implementation) which specifies in particular types of documents. This document is a guide of implementation of the HALF-VALUE LAYER specified within the framework of the perinatality field. The structuring of each document exchanged within this field will be specified point by point and the 1° task to be realized is to define the list of the types of exchanged documents and to define for each one of these documents a “TemplateId” or identifier of the type of document (expressing itself in the shape of a universal identifier of type OID). Each document of the perinatality field will have to be identified in a single and universal way. These identifiers consist of a root of identification which it will be necessary to define within the framework of this project, followed by an extension which identifies in a single way the document under the root of identification. There are several possibilities to define the root of identification: - one can create on the level of IHE France or on the level of HL7-France a perinatality field charged to manage the whole of the documents of the field, the root of identification used is then that of IHE-France, - one can decide that the whole of the documents of the perinatality field will be managed by the DMP-child group, in which case one will use the root of identification of the GIP-DMP-child, - one can decide that the whole of these documents will be managed by the platform of télésanté of Brittany, in which case one will use the root of identification of this field. - etc…</p><p>2.1.3 STYLE SHEETS The systems sources of documents will be able to possibly provide the style sheet associated with the document making it possible to visualize the document correctly. When this style sheet is provided, the bond will have to be referred in the document HALF-VALUE LAYER itself and the style sheet will have to be accessible to any system consuming the document. 2.1.4 THE MODEL GENERAL OF A SECTION A section will have to contain: - a code section (obligatory): code. This code section is associated: O a code of system of coding (obligatory): codeSystem, O a name of system of coding (optional): codeSystemName, O the wording of the code section (obligatory): displayName. - A title of section (optional): [[title]], - That is to say: O One or more elements component in the case where the section is divided into under sections, O Or . A textual element (obligatory): text, which represents the narrative part of the section and which must obligatorily be readable by a user, . A structured element (optional): entry, if the information deferred to the level of this section can be structured and codified. Example: <section> <code code= " 10153-2 " codeSystem= " 2.16.840.1.113883.6.1 " codeSystemName= " LOINC "/> <>Medical Past History< /title> <text> There has off history <content ID= " a1 "> Asthma< /content> </text> <entry> <observation classCode= " OBS " moodCode= " EVN "> <code code= " 195967001 " codeSystem= " 2.16.840.1.113883.6.96 " codeSystemName= " SNOMED CT " displayName= " Asthma "> <originalText> <reference value= " #a1 "/> </originalText> </code> <statusCode code= " completed "/> </observation> </entry> </section> Thus, the specification HALF-VALUE LAYER makes it possible to the actors of the exchange to manage the transition from not structured towards structured. In a document HALF-VALUE LAYER cohabit of the “narrative ” parts (part text) intended for posting, and of the structured “entries ”. A system temporarily unable to manage the structured data will be satisfied to post the data of the narrative part in a navigator (with the assistance or not of a style sheet). A system able to manage the structured data will have, moreover, access to all the detail of the coded data. This ambivalence of HALF-VALUE LAYER is essential to manage the transition from not structured towards structured. In the continuation of the document certain sections will be coded, others not. 2.2 STRUCTURING OF LEVEL 3: ENTRIES</p><p>2.2.1 ENTRIES OF LEVEL 3 DEDICATED TO THE MULTI-MEDIA POSTING OF INFORMATION In the future, the software trade of pediatry will have to be able to generate graphs (curved of growth, curves of weight, etc). The documents exchanged in the field of the perinatality will be likely to contain these graphs or of the simple images (echography type). The HALF-VALUE LAYER describes a particular structure of entry which makes it possible to manage these contents multimedia. <section> <code code= " 8709-8 " codeSystem= " 2.16.840.1.113883.6.1 " codeSystemName= " LOINC "/> <>Skin exam< /title> <text> Erythematous rash, palmar surface, left index finger.< renderMultiMedia referencedObject= "MM1“/> </text></p><p><entry> <observationMedia classCode= " OBS " moodCode= " EVN " ID= "MM1“> <id root= " 2.16.840.1.113883.19.2.1 "/> <been worth xsi: type= " ED " mediaType= " image/JPEG " representation=” B64”> here is the multi-media contents in base64 </value> </observationMedia> </entry> </section> The element renderMultiMedia allows to refer a multi-media object which forms integral part of the medical document. This guide of implementation will restrict the use of this element to the inclusion of the multi-media object bases of them 64 directly in the medical document, without allowing a simple reference to an external object, in order not to have to manage the problems of access to this object. In this case, it is the element observationMedia who is used to code the multi-media object, contrary to the element reference/externalDocument.</p><p>2.2.2 ENTRIES OF LEVEL 3 DEDICATED TO THE EXPLOITTATION OF THE STRUCTURED DATA: Each section described in the documents of the perinatality field will be able to possibly contain a entry containing itself the coded part of the medical data carried by the section. If the narrative part of the section can be derived completion from the coded part, the attribute entry.typeCode will take value “DRIV”, if not it will take value “COMP”. The general rules applicable to all the entries of the field are as follows: - RG1: a entry is characterized by an element code composed of the attributes: O code : coding of a medical data, O codeSystem : identifier of the system of coding used to code the medical data, O codeSystemName: name of the system of coding, O dispalyName : the wording of the code of the medical data. - RG2 : transcoding of the medical information coded in various nomenclatures: O The element translation, within the entry, allows to code a transcoding of the medical data in another nomenclature of which a nomenclature “pivot”. - RG3: construction of the narrative part to leave the coded part: O The element originalText can be used like process of a simple and basic coding. Indeed, this element exists if the actor who generates information initially does not inform it in a coded form, but in a textual form. Coding can be carried out later, by a system or a user. O For example, during the creation of the document, the doctor can seize an allergy in the shape of a character string such that “asthma”. This information will be supplemented later by an other actor who will inform the code of the data “asthma” O The connection between the narrative part (text) and the coded part (entry) is established via the attribute reference element originalText on the level of the entry. This element refers to a local identifier with the file XML-CDA which is defined in the level of the narrative part of the document via the element <content>. Example: <section> <code code= " 10153-2 " codeSystem= " 2.16.840.1.113883.6.1 " codeSystemName= " LOINC "/> <>Medical Past History< /title> <text> There has history content <ID off= " a1 ">Asthma< /content> </text> <entry> <observation classCode= " OBS " moodCode= " EVN "> <code code= " 195967001 " codeSystem= " 2.16.840.1.113883.6.96 " codeSystemName= " SNOMED CT " displayName= " Asthma "> <originalText> <been worth reference= " #a1“/> </originalText> </code> <statusCode code= " completed "/> </observation> </entry> </section> 2.3 SPECIFICATION OF THE DOCUMENT “GENERAL INFORMATION AND ANTECEDENTS”</p><p>2.3.1 STRUCTURING OF LEVEL 2: LIST SECTIONS OF THE DOCUMENT The body of the document is consisted of the following sections: - Psychosocial context of the mother: O Socio-demographic information of the father and the mother, O Psychosocial context, - personal antecedents of the mother: O medical antecedents, O surgical antecedents, O gynéco-obstétricaux antecedents O other antecedents - family antecedents. (antecedents of the members of the family of the mother and the members of the family of the father) - habitus: dependence with the tobacco, dependence with alcohol, drug-addiction, etc - serology, - biometric data of the father and the mother. The body of the document will be composed of the various sections presented below, each section being coded by a code LOINC. Titrate Code The wording loinc card loinc Social context psycho 29762-2 SOCIAL HISTORY 0..1 Biometric data 8716-3 VITAL SIGNS 0..1 Personal antecedents 11322-5 HISTORY OFF GENERAL HEALTH 0..1 Medical antecedents 11348-0 HISTORY OFF PASTILLNESS 0..1 Surgical antecedents 47519-4 HISTORY OFF PROCEDURES 0..1 Gynéco-obstétricaux antecedents 11449-6 PREGNANT STATUS 0..1 Other antecedents 11329-0 GENERAL HISTORY 0..1 Family antecedents 10157-6 HISTORY OFF FAMILY MEMBER DISEASES 0..1 Addiction with alcohol/drug 18663-5 HISTORY OFF PRESENT ALCOHOL AND/OR 0..1 SUBSTANCE MISUSES Addiction with the tobacco 11366-2 HISTORY OFF TOBACCO USES 0..1 Serology 18733-6 Subsequent evaluation notes (attending physician) 0..1 Each section will be built according to the model general of a section describes before in this document.</p><p>2.3.2 STRUCTURING OF LEVEL 3: THE STRUCTURED PART</p><p>2.3.2.1 psychosocial context: 29762-2 (SOCIAL HISTORY) This section identifies information of a social nature, personal (life style), psychological, as well as administrative information such as the marital statute, which can have an impact on the follow-up of the patient by the medical team. This section is optional on level 2 and level 3. The marital statute as all administrative information will be also coded on the level of at the head the HALF-VALUE LAYER and possibly on level 3 For example, it marital statute will be coded on the level of at the head by ClinicalDocument/recordTarget/patientRole/patient/maritalStatusCode. The administrative infos of the psychosocial context are as follows: at the head or coding on the Social level of the section History on the model of Family History (regrouping by organizer of information by member of the family: father, mother). The whole of this information are not described in the header HALF-VALUE LAYER, we will thus code them on the level of the section “Social History” of the body of the document. - family circumstances, - family way of life, - nationality (father and mother), - geographical origin (father and mother), - level of studies (father and mother), - profession (father and mother), - resources of the mother, - Social Security cover of the mother The medical infos are as follows: - situation requiring a social accompaniment, - situation presenting a risk, - important events occurred during the pregnancy This section will be coded by means of the entity <organizer> who allows to gather the whole of the data of the psychosocial context. An element <organizer> will be used for each actor (the patient and its spouse). This element <organizer> will be possibly connected to the beacon <subject> if this information refers to the spouse of the patient. Implicitly, in the case where entity <subject> misses, the observations of the psychosocial type described on the level of the entity <organizer> correspond to the patient. Each information quoted above will be coded by means of an element <observation>. L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [1..1] section/templateId root 2.16.840.1.113883.10.20.15 Social history section template 1.3.6.1 .4.1.19376.1.5.3.1.3.16 social history section for this document shall Be has has conforming social off history section CCC (2.16.840.1.113883.10.20.15) and shall Be has conforming social off history section this guide (1.3.6.1 . 4.1.19376.1.5.3.1.3.16) 1 [1..1] section/code code 29762-2 Code identifying the psychosocial context of the patient (way of life, beliefs, codeSystem 2.16.840.1.113883.6.1 practices of work…)as well as the factors codeSystemName LOINC of risks of the patient displayName 1 [1..1] section/ Titrate section readable by human: “factors of risks” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. The narrative part is deduced from the codified part 2 [1..2] entry/organizer moodCode EVN Fixed by HL7 classCode CLUSTER Values fixed by HL7 3 [1..1] organizer/templateId root PCC codes? nondefinite Social History Organizer Template OID specific to RSN Identification of the model organizer of the social type history (Social History organizer template) 3 [1..1] organizer/statusCode code “completed” fixed Subject participation used yew the subject differs from the recordTarget off the header (e.g. social history information butt the husband) 3 [0..1] organizer/subject typeCode SBJ 4 [0..1] subject/relatedSubject classCode PRS 5 [1..1] relatedSubject/code code HUSB HL7v3 vocabulary (RoleCode) is used to qualify the husband codeSystem 2.16.840.1.113883.5.111 codeSystemName RoleCode displayName “Husband” 6 [0..1] relatedSubject/subjectPerson classCode PSN Extension HALF-VALUE LAYER R2 described in section family history of the CCC * is necessary it to name the spouse on this level or the level of the header? 7 [0..1] subjectPerson/name * 7 [0..1] subjectPerson/birthTime been worth * 7 [0..1] subjectPerson/administrativeGenderCode code M codeSystem 2.16.840.1.113883.5.111 codeSystemName AdministrativeGender displayName Male Content off the Social History Organizer: any number off SocialHistoryObservation 3 [1..*] organizer/component typeCode COMP 4 [1..1] component/observation moodCode EVN Fixed by HL7 classCode OBS 5 [0..1] observation/templateId root 2.16.840.1.113883.10.20.1.33 Social History observation template 2.16.840.1.113883.10.20.1.4.13.4 The relative off this template has simple compatible observation with the CCC template (2.16.840.1.113883.10.20.1.33) 5 [0..1] observation/id root ‘ ‘ extension ‘ ‘ 5 [0..1] observation/code code Cf lists nomenclatures used by this Identification of the system of coding of section the demographic or psychosocial data codeSystem OID RSN (for administrative dated) but 2.16.840.1.113883.6.96 (for medical dated) codeSystemName DPERINAT RSN gold SNOMED- CT displayName 5 [1..1] observation/statusCode code Completed (fixed) 5 [0..1] observation/effectiveTime Been worth Low For example, the period during the patient Been worth Hight was married 5 [0..1] been worth observation/ xsi: type PQ: physical quantity gold This social element carryforwards the CD: coded been worth gold been worth associated with the history, in the box the dated is coded ANY PQ: {xxx} /d or/wk gold /a CD: coded been worth with appropriate vocabulary 5 [0..1] Been worth observation/ xsi: type ST This social element carryforwards the been worth associated with the history, in the box the dated is text 5 [0..1] Been worth observation/ xsi: type been worth BL true or false Precarious conditions of lodging Occupation followed during the pregnancy Table 1: section Social History List nomenclatures associated with this section: Family circumstances: code SITFAM Code the wording 0 Unknown 1 Single person 2 Married (E) 3 divorced 6 pacs Family way of life: code MODFAM Code the wording 0 Unknown 1 Only 2 In couple 3 Other Nationality: code NAT Code the wording 0 Unknown 1 Frenchwoman 17 The EEC 18 Except the EEC 2 Other Geographical origin: code ORIGEO Code the wording 0 Unknown 1 Metropolitan France 2 Northern Europe 3 Europe of the south 4 North Africa 5 Africa 6 Dom-Tom 7 Asia 8 Other Level of studies: code OFFAL Code the wording 0 Unknown 1 Not provided education for 2 Primary education 3 College (6°- 3°) - BEP - CAPE 4 College 5 Higher education Profession: code TEACHER (extracted nomenclature INSEE) Code the wording 0 Unknown 10 farmer 20 craftsman 30 Tally, liberal profession 40 Intermediate profession 51 Employee (E) of the public office or the companies 52 Employee (E) of trade 61 Personnel of service 62 Ouvirer (E) 80 Nobody not having never worked, student Social Security cover: code COUVSOC Code the wording 0 Unknown 1 Social security 2 Secu + mutual 3 CMU 4 HEART 5 other 6 none The concept of conditions of lodging (precarious yes/not) is attached to this concept of Social Security cover. Resources: code LMBO Code the wording 0 work 1 RMI 2 Allowances unemployment 3 API 4 none 5 other Events occurred during the pregnancy: code EVN Code the wording 0 Separation or divorce 1 Family death 2 Job loss 3 other Situation at the risk: code RISQ Code the wording 0 Risk as regards the social aspects 1 Risk on the psychological level 2 As regards the social and psychological aspects ******************************************************* Social History section ******************************************************** --> <component> <section> <templateId root="2.16.840.1.113883.10.20.1.15“/> <! -- Social history section template --> <templateId root="2.16.840.1.113883.10.20.1.16“/> < id root=” “ extension=” “/> <code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC“/> <[[title]]>Social history</[[title]]> <text> <paragraph>Social context psycho of the mother</paragraph> <count to border="1" width="100%“> <tbody> <tr><td>marital status</td><td>57</td></tr> <tr><td>family way of life</td><td>40</td></tr> </tbody> </count> <paragraph> Social context psycho of the father</paragraph> <count to border="1" width="100%“> <tbody> <tr><td> marital status </td><td>30</td></tr> <tr><td>family way of life</td><td>40</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <organizer moodCode="EVN" classCode="CLUSTER“> <templateId root="2.16.840.1.113883.10.20.1.???“/> <! -- Social history organizer template --> <statusCode code="completed“/> <component typeCode="COMP“> <observation classCode="OBS" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.33“/> <! -- Social history observation template --> <templateId root="2.16.840.1.113883.10.20.1.4.13.4" <id root= " “ extension = " “ /> <code code="SITFAM" codeSystem=" OID RSN???" codeSystemName="RSN" displayName="Marital status“/> <statusCode code="completed“/> <effectiveTime><low been worth="1947“/><high been worth="1972“/></effectiveTime> <been worth xsi: type="CD code="1" codeSystem=" OID RSN-SITFAM?" codeSystemName="RSN-SITFAM" displayName="married“/> </observation> </component> <component typeCode="COMP“>> <observation classCode="OBS" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.33“/> <! -- Social history observation template --> <templateId root="2.16.840.1.113883.10.20.1.4.13.4" <id root= " “ extension = " “ /> <code code="MODFAM" codeSystem=" OID RSN???" codeSystemName="MODFAM" displayName="Family way of life “/> <statusCode code="completed“/> <effectiveTime><low been worth="1972“/><high been worth="1980“/></effectiveTime> <been worth xsi: type="CD code="2" codeSystem=" OID RSN-MODFAM??" codeSystemName="RSN-MODFAM" displayName="only saw“/> </observation> </component> </organizer> </entry> <entry typeCode="DRIV“> <organizer moodCode="EVN" classCode="CLUSTER“> <templateId root="2.16.840.1.113883.10.20.1.???“/> <! -- Social history organizer template --> <statusCode code="completed“/> <subject> typeCode ="SBJ“> <relatedSubject classCode="PRS“> <code code="HUSB" codeSystem="2.16.840.1.113883.5.111" codeSystemName = " RoleCode “ displayName="Husband“/> <subjectPersonn> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male“/> <birthTime been worth="1912“/> </subjectPersonn> </relatedSubject> </subject> <component typeCode="COMP“> <observation classCode="OBS" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.33“/> <! -- Social history observation template --> <templateId root="2.16.840.1.113883.10.20.1.4.13.4" <id root= " “ extension = " “ /> <code code="SITFAM" codeSystem=" OID RSN??" codeSystemName="RSN" displayName="Marital status“/> <statusCode code="completed“/> <effectiveTime><low been worth="1947“/><high been worth="1972“/></effectiveTime> <been worth xsi: type="CD code="1" codeSystem=" OID RSN-SITFAM?" codeSystemName="RSN-SITFAM" displayName="married“/> </observation> </component> <component typeCode="COMP“> <observation classCode="OBS" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.33“/> <! -- Social history observation template --> <templateId root="2.16.840.1.113883.10.20.1.4.13.4" <id root= " “ extension = " “ /> <code code="ORIGEO" codeSystem=" OID RSN??" codeSystemName="RSN" displayName="Geographical origin“/> <statusCode code="completed“/> <been worth xsi: type="CD code="1" codeSystem=" OID RSN-ORIGEO?" codeSystemName="RSN-ORIGEO" displayName="metropolitan France “/> </observation> </component> </organizer> </entry> </section></p><p>2.3.2.2 biometric data 8716-3 (Vital signs) This section contains the list of the biometric data of the patient. Codes: LOINC CodeSystem: 2.16.840.1.113883.6.1 codeSystemName: LOINC DisplayName Code Description unit BODY HEIGHT 8302-2 Cut m (MEASURED) BODY WEIGHT 3141-9 Weight kg (MEASURED) ABO+RH GROUP 882-1 Blood group SPOKE 34532-2 Search for irregular antibodies BLOOD PRESSES 18684-1 MT INTRAVASCULA 8480-6 HEAP mmHg R_SYSTOLIC INTRAVASCULA 8480-4 TAD mmHg R_DIASTOLIC This section will be coded by means of the entity <organizer> who allows to gather the whole of the biometric data attached to an individual. An element <organizer> will be used for each actor (the patient and its spouse). This element <organizer> will be possibly connected to the beacon <subject> if this information refers to the spouse of the patient. Implicitly, in the case where entity <subject> misses, the observations of the type given biometric described to the level of the entity <organizer> correspond to information of the patient. Each information quoted above will be coded by means of an element <observation>. L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [1..1] section/templateId root 2.16.840.1.113883.10.20.1.16 Vital relative CCC signs section template 1.3.6.1 .4.1.19376.1.5.3.1.3.25 1 [1..1] section/code code 8716-3 Code identifying the biometric data of the patient codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName 1 [1..1] section/ Titrate section readable by human: “given biometric” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. 2 [1..1] entry/organizer moodCode EVN Fixed by HL7 classCode CLUSTER Values fixed by HL7 3 [1..3] organizer/templateId root 2.16.840.1.113883.10.20.1.32 Vital Signs Organizer Template 2.16.840.1.113883.10.20.1.35 Identification of the model organizer of 1.3.6.1 .4.1.19376.1.5.3.1.4.13.1 the vital type signs (Vital Signs organizer template). Model inherited CCC: vital sign organizer for this document shall Be has has conforming vital off signs organizer CCC (2.16.840.1.113883.10.20.1.35) and shall Be has conforming results organizer (2.16.840.1.113883.10.20.1.32) 3 [0..1] Organizer/id root ‘ ‘ extension ‘ ‘ 3 [1..1] organizer/code code 46680005 codeSystem 2.16.840.1.113883.6.96 codeSystemName SNOMED-CT displayName Vital Signs 3 [1..1] organizer/statusCode code “completed” fixed 3 [1..1] organizer/effectiveTime been worth To indicate when the measurement was taken Subject participation used yew the subject differs from the recordTarget off the header (e.g. vital Signs information butt the husband) 3 [0..1] organizer/subject typeCode SBJ 4 [0..1] subject/relatedSubject classCode PRS 5 [1..1] relatedSubject/code code HUSB Coding with the HL7v3 vocabulary codeSystem 2.16.840.1.113883.5.111 codeSystemName RoleCode displayName “Husband” 6 [0..1] relatedSubject/subjectPerson classCode PSN Extension HALF-VALUE LAYER R2 described in section family history of the CCC * is necessary it to name the spouse on this level or the level of the header? 7 [0..1] subjectPerson/name * 7 [0..1] subjectPerson/birthTime been worth * 7 [0..1] subjectPerson/administrativeGenderCode code M codeSystem 2.16.840.1.113883.5.111 codeSystemName AdministrativeGender displayName Male Content off the Vital Signs Organizer 3 [1..*] organizer/component typeCode COMP 4 [1..1] component/observation moodCode EVN Fixed by HL7 classCode OBS Content off the Vital Signs Observation 5 [0..1] observation/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.4.13 With vital signs observation shall cuts 2.16.840.1.113883.10.20.1.31 the <templateId> elements shown 1.3.6.1 .4.1.19376.1.5.3.1.4.13.2 above to indicate that it inherits constraints from Vital the ASTM/HL7 CCC Specification for signs, and the constraints off this specification. </p><p> vital sign observation for this document shall Be has has conforming vital off signs observation CCC (2.16.840.1.113883.10.20.1.31) and shall Be has conforming simple observation (2.16.840.1.113883.10.20.1.13.2) 5 [0..1] Observation/id root ‘ ‘ extension ‘ ‘ 5 [1..1] observation/code code Single vital code off the signs Single code off the vital Signs observation observation: codeSystem 2.16.840.1.113883.6.1 Body height: 8302-2 Body weignt: 3141-9 codeSystemName LOINC ABO+RH group: 882-1 displayName SPOKE: 34532-2 Blood presses: 18684-1 Intravascula R-systolic: 8480-6 Intravascula R-diastolic: 8462-4 5 [1..1] observation/statusCode code Completed (fixed) 5 [0..1] observation/effectiveTime been worth For example, the date the weight was recorded 5 [1..1] been worth observation/ Xsi: type PQ: physical quantity Weight: kg Blood pressure: mm [Hg] been worth To register the value of the data Cut: m weight, size, blood pressure, etc links Unit used ******************************************************* Vital Signs section ******************************************************** --> <component> <section> <templateId root="2.16.840.1.113883.10.20.1.16“/> <! -Conform Vital to PCC signs section template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.3.25“/> <! -- Vital signs section template --> <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <[[title]]>Biometric data</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT align="right“>Date/time: </HT><HT>Nov. 14, 1999</HT><HT>April 7, 2000</HT></tr> </thead> <tbody> <tr><HT align="left“>Cut</HT><td>177 cm</td><td>177 cm</td></tr> <tr><HT align="left“>Weight</HT><td>86 kg</td><td>88 kg</td></tr> <tr><HT align="left“>Blood pressure</HT><td>132/86 mmHg</td><td>145/88 mmHg</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <organizer classCode="CLUSTER" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.32“/> <! -- Vital signs organizer template --> <templateId root="2.16.840.1.113883.10.20.1.35“/> <! -CCC Vital signs organizer template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.1“/> <! -Vital PCC signs organizer template --> <id root= " “ extension= " “ /> <code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT” displayName="Vital signs“/> <statusCode code="completed“/> <effectiveTime been worth="19991114“/> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <templateId root="2.16.840.1.113883.10.20.1.31“/> <! -CCC Result observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.2“/> <! -- Result observation template --> <id root= " “ extension= " “ /> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC” displayName="Body height“/> <statusCode code="completed“/> <effectiveTime been worth="19991114“/> <been worth xsi: type="PQ" been worth="177" links="cm“/> </observation> </component > <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <templateId root="2.16.840.1.113883.10.20.1.31“/> <! -CCC Result observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.2“/> <! -- Result observation template --> <id root= " “ extension= " “ /> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC” displayName="Body weight“/> <statusCode code="completed“/> <effectiveTime been worth="19991114“/> <been worth xsi: type="PQ" been worth="86" links="kg“/> </observation> </component> </organizer> </entry> <entry typeCode="DRIV“> <organizer classCode="CLUSTER" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.32“/> <! -- Vital signs organizer template --> <templateId root="2.16.840.1.113883.10.20.1.35“/> <! -- Vital signs organizer template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.1“/> <! -- Vital signs organizer template --> <id root= " “ extension= " “ /> <code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT” displayName="Vital signs“/> <statusCode code="completed“/> <effectiveTime been worth="20000407“/> <subject> typeCode ="SBJ“> <relatedSubject classCode="PRS“> <code code="HUSB" codeSystem="2.16.840.1.113883.5.111" codeSystemName = " RoleCode “ displayName="Husband“/> <subjectPersonn> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male“/> <birthTime been worth="1912“/> </subjectPersonn> </relatedSubject> </subject> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <templateId root="2.16.840.1.113883.10.20.1.31“/> <! -CCC Result observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.2“/> <! -- Result observation template --> <id root= " “ extension= " “ /> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC” displayName="Body height“/> <statusCode code="completed“/> <effectiveTime been worth="20000407“/> <been worth xsi: type="PQ" been worth="190" links="cm“/> </observation> </component> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <templateId root="2.16.840.1.113883.10.20.1.31“/> <! -CCC Result observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.2“/> <! -- Result observation template --> <id root= " “ extension= " “ /> <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC” displayName="Body weight“/> <statusCode code="completed“/> <effectiveTime been worth="20000407“/> <been worth xsi: type="PQ" been worth="90" links="kg“/> </observation> </component> </organizer> </entry> </section> 2.3.3 PERSONAL ANTECEDENTS 11322-5 This section gathers the whole of the antecedents of the patient (medical, surgical, gynéco-obstétricaux and different) or of a person close to the patient (his/her husband for example). An information processing system which could not typify the antecedent will use the sub-section “other antecedents”. The antecedents will be listed more recent with oldest. The nomenclature pivot used to code the personal antecedents is the CIM10. In order to facilitate the interworking of the exchanges between the various systems, other nomenclatures could be proposed. As soon as a transcoding CIM10 of native coding is known, it will have to be specified by the means of the element translation.</p><p>2.3.4 MEDICAL ANTECEDENTS (11348-0) The medical antecedents of the patient are modelled by an entity <organizer> composed itself of a whole of modelled medical problems each one by an entity <observation>. For the spouse, it is simply asked to indicate if this one is reached or not pathology (use of Boolean) and to specify by a textual element (uncoded) this pathology. The element <organizer> will be possibly connected to the beacon <subject> if the medical antecedents refer to the spouse of the patient. Implicitly, if entity <subject> misses, the observations of the type given biometric described to the level of the entity <organizer> correspond to information of the patient. L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [1..1] section/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.3.8 Resolved Problems section template 1 [1..1] section/code code 11348-0 (PCCp172) Code identifying the list of the last personal medical antecedents. codeSystem 2.16.840.1.113883.6.1 Patient This section lists and describe codeSystemName LOINC the conditions the suffered in the past displayName HISTORY OFF PAST ILLNESS 1 [1..1] section/ Titrate section readable by human: “previous medical” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. Subject participation used yew the subject differs from the recordTarget off the header (e.g. Pb list butt the husband) 2 [0..1] entry/subject typeCode SBJ 3 [0..1] subject/relatedSubject classCode PRS 4 [1..1] relatedSubject/code code HUSB codeSystem 2.16.840.1.113883.5.111 codeSystemName RoleCode displayName “Husband” 4 [0..1] relatedSubject/subjectPerson classCode PSN Extension HALF-VALUE LAYER R2 described in section family history of the CCC * is necessary it to name the spouse on this level or the level of the header? 5 [0..1] subjectPerson/name * 5 [0..1] subjectPerson/birthTime been worth * 5 [0..1] subjectPerson/administrativeGenderCode code M codeSystem 2.16.840.1.113883.5.111 codeSystemName AdministrativeGender displayName Male Description off one gold more problems 2 [1..1] entry/observation moodCode EVN Fixed by HL7. classCode OBS The clinical statement should include one gold more problem acts. 3 [1..2] observation/templateId root 2.16.840.1.113883.10.20.1.28 Problem Entry template: act of 1.3.6.1 .4.1.19376.1.5.3.1.4.5. recording event “being concerned with Pb or an allergy” concerning the this entry has specialization off the condition of the patient. Concern Entry wherein the subject off concern is focused one has This entry has has template to identify problem. 1.3.6.1 .4.1.19376.1.5.3.1.4.5 off, and is compatible with the ASTM/HL7 Continuity off Care Document template: 2.16.840.1.113883.10.20.1.28 3 [0..1] observation/id Root ‘’ extension ‘’ 3 [0..1] observation/code code CIM10 One uses the CIM10 to code the medical antecedent codeSystem 2.16.840.1.113883.6.96 codeSystemName SNOMED CT displayName 3 [0..1] /statusCode observation code completed</p><p>3 [0..1] /effectiveTime observation Been worth Low Been worth Hight 3 [1..1] Been worth observation/ Xsi: type CD Been worth The is the condition that was found code Code corresponding in SNOMED or CIM10 codeSystem 2.16.840.1.113883.6.96 (SNOMED) or 2.16.840.113883.6.3 (CIM10) codeSystemName SNOMED CT or CIM10 displayName originalText/been URI who points on the free text of worth reference description of the problem 3 [0..1] Observation/entryRelationShip typeCode SUBJ Fixed inversionInd true Contains in an optional way: A severity observation (template 1.3.6.1 .4.1.19376.1.5.3.1.4.1) A clinical status off the Pb (template . 3.6.1.4.1.19376.1.5.3.1.4.1.1) Health status off patient (template . 3.6.1.4.1.19376.1.5.3.1.4.1.1 Severity off the problem 4 [0..1] entryRelationship/observation moodCode EVN The related statement is another vent (moodCode=' EVN') observing classCode OBS (<observation classCode=' OBS'>) the severity off the (surrounding) related entry (e.g., has condition gold Al). 5 [1..2] Observation/tempateId root 2.16.840.1.113883.10.20.1.55 The <templateId> elements identify 3.6.1.4 .1.19376.1.5.3.1.4.1 this <observation> have has severity observation, Al for validation off the content 5 [1..1] observation/code code SEV codeSystem 2.16.840.1.113883.5.4 codeSystemName ActCode displayName Severity 5 [1..1] observationText/reference been worth “#severity-2” The <text> elements shall contain has <reference> element pointing to the narrative where the severity is recorded, rather than duplicate text to avoid ambiguity 5 [1..1] observation/statusCode code `completed' 5 [0..1] been worth observation/ xsi: type CD Level of severity (high, medium, low) code H|M|L codeSystEM 2.16.840.1.113883.5.1063 dispalyName SeverityObservation 6 [0..1] observation/entryrelationship typeCode REFR Year optional <entryRelationship> may present Be indicating the clinical status off the problem, e.g., resolved, in remission, active. Present When, this inversionInd true <entryRelationship> element shall contain has clinical status observation conforming to the Problem Status Observation Clinical status off the problem 4 [1..1] observation classCode OBS This specification models has problem status observation have has separate moodCode EVN observation from the problem. 5 [1..3] observation/templateId root 2.16.840.1.113883.10.20.1.57 To identify template off the Problem 2.16.840.1.113883.10.20.1.50 Status Observation conform to the Status Observation off CCC 1.3.6.1 .4.1.19376.1.5.3.1.4.1.1 (2.16.840.1.113883.10.20.1.57) and conform to the Problem Status Observation off CCC (2.16.840.1.113883.10.20.1.50) 5 [1..1] observation/code code 33999-4 This observation is off clinical status, have indicated by the <code> element. codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC</p><p> displayName Status This element must present Be. The codes and codeSystem shall Be 5 [1..1] observation/text/reference been worth `#cstatus-2” The <observation> element shall contain has <text> element that points to the narrative text describing the clinical status. The <text> elements shall contain has <reference> element pointing to the narrative section 5 [1..1] observation/statusCode code `completed' 5 [1..1] been worth observation/ xsi: type EC Been worth <The> element contains the clinical status code `' cf counts of the statutes Cf counts statute relating to this section codeSystEM 2.16.840.1.113883.6.96 codeSystemName SNOMED-CT dispalyName ‘’ 6 [0..1] observation/entryrelationship typeCode SUBJ Year optional <entryRelationship> may present Be providing year additional how (annotation) for the condition. Present When, this inversionInd true <entryRelationship> element shall contain has how observation conforming to the How entry.</p><p>How off the problem 4 [1..1] act classCode ACT This specification models has how have year act. moodCode EVN 5 [1..2] act/templateId root 2.16.840.1.113883.10.20.1.40 Compatible This template is with the 1.3.6.1 .4.1.19376.1.5.3.1.4.1.2 CCC how template: 2.16.840.1.113883.10.20.1.40 5 [1..1] act/code code 48767-8 codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName Annotation how 5 [1..1] act/text/reference been worth `#comment-2” The <observation> element shall contain has <text> element that points to the narrative text describing the clinical status. The <text> elements shall contain has <reference> element pointing to the narrative section 5 [1..1] act/statusCode code `completed' 5 [0..1] Act/author time EC Been worth <The> element contains the clinical status assignedAuthor Cf counts 2</p><p>Count of the statutes of the problems: Code the wording 55561003 Active 734225007 Inactive 90734009 Chronicle 7087005 Intermittent 255227004 Recurring 415684004 Rule out 410516002 Ruled out 413322009 Resolved ******************************************************** Problems section ******************************************************** <component> <section> <templateId root=1.3.6.1 .4.1.19376.1.5.3.1.3.8'/> <! -- Problem section template --> <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC“/> <[[title]]>Medical antecedents</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT>Pathology</HT><HT>Date</HT><HT>Statute </HT></tr> </thead> <tbody> <tr><td>Asthma</td><td>1950</td><td>Active</td></tr> <tr><td>Pneumonia</td><td>Jan 1997</td><td>Resolved</td></tr> <tr><td>Myocardial Infarction</td><td>Jan 1997</td><td>Resolved</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root='2.16.840.1.113883.10.20.1.28'/> <! -- Problem template --> <templateId root=”1.3.6.1 .4.1.19376.1.5.3.1.4.5”/> <! -- Problem template --> <id root= " “ extension= " “/> <code code= " CIM10 " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT” displayName="CIM10“/> <statusCode code="completed“/> <entryRelationship typeCode="SUBJ" inversinInd="true“ > <observation classCode="OBS" moodCode="EVN“> <templateId root='2.16.840.1.113883.10.20.1.57'/> <! -- Problem status observation template --> <templateId root='2.16.840.1.113883.10.20.1.50'/> <! -- Problem status observation template --> <templateId root='1.3.6.1.4 .1.19376.1.5.3.1.4.1.1'/> <! -- Problem status observation template --> <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status“/> <statusCode code="completed“/> <been worth xsi: type="EC" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Active“/> </observation> </entryRelationship> <effectiveTime been worth="1950“/> <been worth xsi: type="CD" code="coding of the ashtme in cIM10" codeSystem="2.16.840.1.113883.6.3" codeSystemName="CIM10” displayName="Asthma" <originalText ><reference been worth=" Asthma “/></originalText> </been worth> </observation> </entry> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root='2.16.840.1.113883.10.20.1.28'/> <! -- Problem template --> <templateId root=”1.3.6.1 .4.1.19376.1.5.3.1.4.5”/> <! -- Problem template --> <id root= " “ extension= " “/> <code code= " CIM10 " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT” displayName="CIM10“/> <statusCode code="Resolved“/> <entryRelationship typeCode="SUBJ" inversinInd="true“ > <observation classCode="OBS" moodCode="EVN“> <templateId root='2.16.840.1.113883.10.20.1.57'/> <! -- Problem status observation template --> <templateId root='2.16.840.1.113883.10.20.1.50'/> <! -- Problem status observation template --> <templateId root='1.3.6.1.4 .1.19376.1.5.3.1.4.1.1'/> <! -- Problem status observation template --> <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status“/> <statusCode code="completed“/> <been worth xsi: type="EC" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Resolved“/> </observation> </entryRelationship> <effectiveTime been worth="Jan 1997“/> <been worth xsi: type="CD" code="coding of pneumonia in cIM10" codeSystem="2.16.840.1.113883.6.3" codeSystemName="CIM10” displayName="Pneumonia" <originalText ><reference been worth=" Pneumonia “/></originalText> </been worth> </observation> </entry> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root='2.16.840.1.113883.10.20.1.28'/> <! -- Problem template --> <templateId root=”1.3.6.1 .4.1.19376.1.5.3.1.4.5”/> <! -- Problem template --> <id root= " “ extension= " “/> <code code= " CIM10 " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT” displayName="CIM10“/> <statusCode code="Resolved“/> <entryRelationship typeCode="SUBJ" inversinInd="true“ > <observation classCode="OBS" moodCode="EVN“> <templateId root='2.16.840.1.113883.10.20.1.57'/> <! -- Problem status observation template --> <templateId root='2.16.840.1.113883.10.20.1.50'/> <! -- Problem status observation template --> <templateId root='1.3.6.1.4 .1.19376.1.5.3.1.4.1.1'/> <! -- Problem status observation template --> <code code="33999-4" codeSystem="2.16.840.1.113883.6.1" displayName="Status“/> <statusCode code="completed“/> <been worth xsi: type="EC" code="55561003" codeSystem="2.16.840.1.113883.6.96" displayName="Resolved“/> </observation> </entryRelationship> <effectiveTime been worth="Jan 1997“/> <been worth xsi: type="CD" code="coding of the infection of the myocardium in cIM10" codeSystem="2.16.840.1.113883.6.3" codeSystemName="CIM10” displayName="Myocardium infection" <originalText ><reference been worth=" Myocardium infection “/></originalText> </been worth> </observation> </entry> </section> </component> 2.3.5 SURGICAL ANTECEDENTS 47519-4 Uncoded section, the narrative part is indicated starting from the element text contents in the coded part. section 47519-4 (HISTORY OFF PROCEDURES) L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [0..1] section/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.3.11 List off surgeries section template 2.16.840.1.113883.10.20.1.12 CCC Relative template to identify for procedure section 1 [1..1] section/code code 47519-4 Code identifying the list of the last surgical operations. codeSystem 2.16.840.1.113883.6.1 This operative section lists and codeSystemName LOINC describe the diagnosis and therapeutic displayName HISTORY OFF PROCEDURES procedures in the past 1 [1..1] section/ Titrate section readable by human: “previous surgical” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. 2 [1..1] entry/procedure moodCode EVN Fixed by HL7 classCode PROC Values fixed by HL7 3 [1..1] /templateId procedure root 2.16.840.1.113883.10.20.1.29 CCC Procedure Template (vent mood) 1.3.6.1 .4.1.19376.1.5.3.1.4.19 Conform to Procedure entry template 3 [1..1] /id procedure root extension 3 [1..1] /code procedure code Code identifying the last intervention. codeSystem 2.16.840.1.113883.5.4 codeSystemName ActCode displayName 3 [1..1] /text procedure Been worth reference #xxx Reference to the descriptive text of the procedure 3 [1..1] /statusCode procedure code completed 3 [0..1] /effectiveTime procedure Been worth Low Date to which the problem intervened ******************************************************** List off surgeries section ******************************************************** <component> <section> <templateId root="2.16.840.1.113883.10.20.1.12“/> <! -Conform to PCC Procedure section template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.3.11“/> <! -List off surgeries section template --> <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <[[title]]>Surgical antecedents</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT>Procedure</HT><HT>Date</HT></tr> </thead> <tbody> <tr><td><content ID="Proc1“>Total hip replacement</content></td><td>1998</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <procedure classCode="PROC" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.29“/> <! -PCC Procedure activity template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.19“/> <! - Procedure entry template --> <id root= "" extension= ""/> <code code="" codeSystem="2.16.840.1.113883.5.4" codeSystem="ActCode“/> <originalText><reference been worth="#Proc1“/></originalText> <statusCode code="completed“/> <effectiveTime been worth="1998“/></p><p></procedure> </entry> </section> </component></p><p>2.3.6 GYNÉCO-OBSTÉTRICAUX ANTECEDENTS 11449-6 Uncoded section, the narrative part is indicated starting from the element text contents in the coded part. section 10162-6 (PREGNANCY HISTORY SECTION) L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [0..1] section/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.1.5.3.4 PCC Pregnancy history section template 1 [1..1] section/code code 10162-6 Code identifying the section of the gynéco-obstétricaux antecedents. codeSystem 2.16.840.1.113883.6.1 This operative section lists and codeSystemName LOINC describes the diagnosis and therapeutic displayName HISTORY OFF PREGNANCIES procedures in the past 1 [1..1] section/ Titrate section readable by human: “previous gynéco-obstétricaux” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. 2 [1..1] entry/observation moodCode EVN Fixed by HL7 classCode OBS Values fixed by HL7 3 [1..1] /templateId observation root 1.3.6.1 .4.1.19376.1.5.3.1.4.13 Pregnancy Template Observation 1.3.6.1 .4.1.19376.1.5.3.1.4.13.5 p320 PCC 3 [1..1] /id observation root extension 3 [1..1] /code observation code Code identifying the code of the observation, by means of a local codeSystem OID RSN + ident nomenc nomenclature (local use d'1 nomenc codeSystemName ANTCGYNECO rather than Loinc bus difficulty of coding the age of the 1° rules and displayName regularity of the cycles. : 8678-5 : menstrual status 8665-2 : date last menstrual period p321 PCC age of the 1° rules? Regularity of the cycles? (menstrual status?) 3 [1..1] /text observation Been worth reference #xxx Reference to the descriptive text of the observation 3 [1..1] /statusCode observation code completed 3 [0..1] /effectiveTime observation been worth Date to which the observation intervened 3 [0..1] /value observation Xsi: type CD been worth Value of the code in nomenclature ANTCGYNECO Gynaecological pathologies to announce are as follows : Genital herpes Lesions will intra epithelial Cicatricial uterus of gynaecological origin Fibrome untreated Genital malformation other ******************************************************** Pregnancy history section ******************************************************** <component> <section> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.1.5.3.4“/> <! -Pregnancy History section template --></p><p><code code="10162-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" /> <[[title]]>Gynéco-obstétricaux antecedents</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT>Gynaecological antecedents</HT><HT>Date</HT></tr> </thead> <tbody> <tr><td><content ID="Ant1“>Genital herpes></td><td>2000</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13 “/> <! -PCC Pregnancy observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.5“/> <! - PCC Pregnancy observation template --> <id root= "" extension= ""/> <been worth xsi: type="CD" code="coding of the antecedent gyneco in nomenclature ANTCGYNECO" codeSystem=" OID nomenclature ANTCGYNECO " codeSystemName="ANTCGYNECO” <originalText><reference been worth="#Ant1“/></originalText> <statusCode code="completed“/> <effectiveTime been worth="2000“/></p><p></observation> </entry> </section> </component> 2.3.7 FAMILY ANTECEDENTS 10157-6 The family antecedents of the patient are modelled by an entity <organizer> composed itself of a whole of modelled family antecedents each one by an entity <observation>. It is simply asked to indicate if the person is reached or not pathology (use of Boolean) and to specify by a textual element (uncoded) this pathology. The element <organizer> will be possibly connected to the beacon <subject> if the family antecedents refer to a member of the family of the spouse of the patient. Implicitly, if entity <subject> misses , the observations of the antecedents type described on the level of the entity <organizer> correspond to the family antecedents of a member of the family of the patient. L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [1..1] section/templateId root 2.16.840.1.113883.10.20.1.4 CCC Relative Medical Family History 1.3.6.1 .4.1.19376.1.5.3.1.3.14 section template PCC Medical Family History section template 1 [1..1] section/code code 10157-6 Code identifying the family antecedents codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName 1 [1..1] section/ Titrate section readable by human: “previous family” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. 2 [1..1] entry/organizer moodCode EVN Fixed by HL7 classCode CLUSTER Values fixed by HL7 3 [1..3] organizer/templateId root 2.16.840.1.113883.10.20.1.23 PCC Family History Organizer 1.3.6.1 .4.1.19376.1.5.3.1.4.15 Template CCC Family History Organizer 3 [1..1] Organizer/statusCode code “ completed” fixed Subject participation used yew the subject differs from the recordTarget off the header (e.g. family history information butt the husband) 3 [0..1] organizer/subject typeCode SBJ 4 [0..1] subject/relatedSubject classCode PRS 5 [1..1] relatedSubject/code code FAMEMB Coding with the HL7v3 vocabulary codeSystem 2.16.840.1.113883.5.111 codeSystemName RoleCode displayName “Family member” 6 [0..1] relatedSubject/subjectPerson classCode PSN Extension HALF-VALUE LAYER R2 described in section family history of the CCC * is necessary it to name the spouse on this level or the level of the header? 7 [0..1] subjectPerson/name * 7 [0..1] subjectPerson/birthTime been worth * 7 [0..1] subjectPerson/administrativeGenderCode code M codeSystem 2.16.840.1.113883.5.111 codeSystemName AdministrativeGender displayName Male Content off the Family History Organizer 3 [1..*] organizer/entryRelationship typeCode COMP 4 [1..1] entryRelationship/observation moodCode EVN Fixed by HL7 classCode OBS Content off the Family History Observation 5 [0..1] observation/templateId root 2.16.840.1.113883.10.20.1.22 PCC family History observation 1.3.6.1 .4.1.19376.1.5.3.1.4.13.3 Family History observation 5 [0..1] Observation/id root ‘ ‘ extension ‘ ‘ 5 [1..1] observation/statusCode code Completed (fixed) 5 [1..1] Observation/code code ???? to define by DPERINAT-RSN Code family antecedent defined in field DPERINAT-RSN (nomenclature RSN- codeSystem OID RSN-ANTFAM??? ANTFAM) codeSystemName DPERINAT-RSN displayName 5 [1..1] been worth observation/ xsi: type BL: Boolean The patient or her spouse is concerned or not with this antecedent been worth True gold false Nomenclature of the family antecedents in the field périnat Country of the Loire. Is necessary it to use a standardized nomenclature? Code the wording ? Gemellity ? Malformations ? Genetic disease ? Chromosomal disease ? Diabetes ? HTA ? Phlebitis ? Dysplasy of the hip ? Others ******************************************************* Family History section ******************************************************** --> <component> <section> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.3.14“/> <! -CCC Family history section template --> <templateId root="2.16.840.1.113883.10.20.1.4“/> <! -- Family history section template --> <code code="10157-6" codeSystem="2.16.840.1.113883.6.1“/> <[[title]]>Family antecedents</[[title]]> <text> <paragraph>Family of the father</paragraph> <count to border="1" width="100%“> <thead> <tr><HT>Diagnosis</HT></tr> </thead> <tbody> <tr><td>Gemelity</td></tr> <tr><td>Genetic disease</td></tr> </tbody> </count> <paragraph>Family of the mother</paragraph> <count to border="1" width="100%“> <thead> <tr><HT>Diagnosis</HT></tr> </thead> <tbody> <tr><td>Diabetes</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <organizer moodCode="EVN" classCode="CLUSTER“> <templateId root="2.16.840.1.113883.10.20.1.23“/> <! -PCC Family history organizer template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.15“/> <! -- Family history organizer template --> <statusCode code="completed“/> <effectiveTime been worth="20000407“/> <subject> typeCode ="SBJ“> <relatedSubject classCode="PRS“> <code code="FAMMEMB" codeSystem="2.16.840.1.113883.5.111" codeSystemName = " RoleCode “ displayName="Family member“/> <subjectPersonn> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male“/> <birthTime been worth="1912“/> </subjectPersonn> </relatedSubject> </subject> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“></p><p><templateId root="2.16.840.1.113883.10.20.1.22“/> <! -PCC Family history observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.32.16.840.1.113883.10.20.1.22“/> <! -Family history observation template --> <id root= "" extension= ""/> <code code="????" codeSystem=" OID RSN-ANTFAM???" codeSystemName = " DPERINAT-RSN “ displayName="Gemellity“/> <statusCode code="completed“/> <been worth xsi: type="BL" been worth="True"/> </observation> </component> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“></p><p><templateId root="2.16.840.1.113883.10.20.1.22“/> <! -PCC Family history observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.32.16.840.1.113883.10.20.1.22“/> <! -Family history observation template --> <id root= "" extension= ""/> <code code="????" codeSystem=" OID RSN-ANTFAM???" codeSystemName = " DPERINAT-RSN “ displayName="Genetic disease“/> <statusCode code="completed“/> <been worth xsi: type="BL" been worth="True"/> </observation> </component> </organizer> </entry> <entry typeCode="DRIV“>> <organizer moodCode="EVN" classCode="CLUSTER“> <templateId root="2.16.840.1.113883.10.20.1.23“/> <! -PCC Family history organizer template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.15“/> <! -- Family history organizer template --> <statusCode code="completed“/> <effectiveTime been worth="20000407“/> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“></p><p><templateId root="2.16.840.1.113883.10.20.1.22“/> <! -PCC Family history observation template --> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13.32.16.840.1.113883.10.20.1.22“/> <! -Family history observation template --> <id root= "" extension= ""/> <code code="????" codeSystem=" OID RSN-ANTFAM???" codeSystemName = " DPERINAT-RSN “ displayName="Diabetes“/> <statusCode code="completed“/> <been worth xsi: type="BL" been worth="True"/> </observation> </component> </organizer> </entry> </section> </component> 2.3.8 OTHER ANTECEDENTS 10157-6 Uncoded section, the narrative part is indicated starting from the element text contents in the coded part. L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [0..1] section/templateId root ???? General history section template 1 [1..1] section/code code 11329-0 Code identifying the section of the different antecedents. codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName 1 [1..1] section/ Titrate section readable by human: “other antecedents” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. 2 [1..1] entry/observation moodCode EVN Fixed by HL7 classCode OBS Values fixed by HL7 3 [1..1] /templateId observation root ???? Template observation 3 [1..1] /id observation root extension 3 [1..1] /code observation code codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName 3 [1..1] /text observation Been worth reference #xxx Reference to the descriptive text of the observation 3 [1..1] /statusCode observation code completed 3 [0..1] /effectiveTime observation been worth Date to which the observation intervened 3 [0..1] /value observation Xsi: type Value of the code according to the unit ******************************************************** section other antecedents ******************************************************** <component> <section> <templateId root="??????“/> <! - section template --></p><p><code code="11329-0" codeSystem="2.16.840.1.113883.6.1“ codeSystemName="LOINC" /> <[[title]]>Others Antecedents</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT>Antecedent</HT><HT>Date</HT></tr> </thead> <tbody> <tr><td><content ID="Ant1“>Traffic accident ></td><td>2000</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="??????? “/> <! -observation template --> <id root= "" extension= ""/> <code code="" codeSystem="2.16.840.1.113883.6.1" codeSystem="LOINC“/> <originalText><reference been worth="#Ant1“/></originalText> <statusCode code="completed“/> <effectiveTime been worth="2000“/></p><p></observation> </entry> </section> </component> 2.3.9 ADDICTION WITH THE TOBACCO (HISTORY OFF TOBACCO USES) 11366-2 Section 11366-2 (HISTORY OFF TOBACCO USES SECTION). This section does not comprise coded entries Rajout of a bond with the person concerned. L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [0..1] section/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.1.9.8 PCC History off tobacco uses section template 1 [1..1] section/code code 11366-2 Code identifying the section of the dependences to the tobacco. codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName HISTORY OFF TOBACCO USES 1 [1..1] section/text Contents readable by human of the section (left narrative) 1 [1..1] section/ Titrate section readable by human: “dependence with the tobacco” Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. 2 [1..1] entry/observation classCode OBS Fixed by HL7 moodCode EVN Values fixed by HL7 3 [1..1] observation/templateId root ???? History off tobacco uses observation template 3 [1..1] Observation/id root ‘’ extension ‘’ 3 [1..1] Observation/code code 230056004 codeSystem 2.16.840.1.113883.6.96 codeSystemName SNOMED-CT displayName Cigarette smoking 3 [1..1] Observation/statusCode code `completed ` 3 [1..1] Observation/effectiveTime Been worth Low Been worth High 3 [1..1] Been worth observation/ Xsi: type `ST' Tobacco: <10cg/jour; >10cg/jour; not been worth Subject pParticipation used to link the tobacco uses observation to the pregnant episode 3 [0..1] Observation/relationShip typeCode SUBJ inversionInd “true” 4 [1..1] relationShip/observation classCode `OBS ` moodCode “EVN” 5 [1..1] Observation/templateId root 2.16.840.1.113883.10.20.1.41 Episode observation template Allows to model a addiction with the tobacco in bond with the episode of care pregnancy 4 [1..1] Observation/statusCode code `completed ` 4 [1..1] ObservationstatusCodecode code `ASSERTION ` codeSystem 2.16.840.1.113883.5.4 4 [1..1] Been worth observation/ Xsi: type `CD ` Coding of the episode of care pregnancy code ????? codeSystem displayName Subject participation used yew the subject differs from the recordTarget off the header (e.g tobacco uses for the husband) 2 [0..1] Sectionobservation/subject typeCode SUBJ 3 [0..1] SSubject/relatedSubject classCode PRS 3 [1..1] relatedSubject/code code HUSB Coding with the HL7v3 vocabulary codeSystem 2.16.840.1.113883.5.111 codeSystemName RoleCode displayName “Husband” 4 [0..1] relatedSubject/SSubjectPerson classCode PSN Extension HALF-VALUE LAYER R2 described in section family history of the CCC * is necessary it to name the spouse on this level or the level of the header? 5 [0..1] SSubjectPerson/name * 5 [0..1] SSubjectPerson/birthTime been worth * 5 [0..1] SSubjectPerson/administrativeGenderCode code M codeSystem 2.16.840.1.113883.5.111 codeSystemName administrativeGender displayName Male ******************************************************** History off tobacco uses section ******************************************************** --> <component> <section> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.1.9.8“/> <! -History off tobacco uses section template --> <code code="11366-2" codeSystem="2.16.840.1.113883.6.1“/> <[[title]]>Addiction with the tobacco</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT>Addiction with the tobacco</HT><HT> Dates</HT></tr> </thead> <tbody> <tr><td>Before pregnancy</td><td>1 pack per day</td><td>1947 - 1972</td></tr> <tr>After pregnancy<td>"</td><td>Nun</td><td>1973 - </td></tr></p><p></tbody> </count> </text> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="?????“/> <! -History off tobacco uses observation template --> <id root= " “/> <code code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking“/> <statusCode code="completed“/> <effectiveTime><low been worth="1947“/><high been worth="1972“/></effectiveTime> <been worth xsi: type="ST“>1 pack per day</been worth> </observation> </entry> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="????“/> <! -History off tobacco uses observation template --> <id root= " “/> <code code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking“/> <statusCode code="completed“/> <effectiveTime><low been worth="1973“/></effectiveTime> <been worth xsi: type="ST“>Nun</been worth> <entryRelationship typeCode="SUBJ" inversionInd="true“> <observation classCode="OBS" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.41“/> <! -- Episode observation template --> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4“/> <statusCode code="completed“/> <been worth xsi: type="CD" code="????" codeSystem="2.16.840.1.113883.6.96" displayName="Pregnancy“> </been worth> <entryRelationship typeCode="SAS“> <observation classCode="OBS" moodCode="EVN“> <id root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1“/> <code code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking“/> </observation> </entryRelationship> </observation> </entryRelationship> </observation> </entry> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="?????“/> <! -History off tobacco uses observation template --> <id root= " “/> <subject> typeCode ="SBJ“> <relatedSubject classCode="PRS“> <code code="HUSB" codeSystem="2.16.840.1.113883.5.111" codeSystemName = " RoleCode “ displayName="Husband“/> <subjectPersonn> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male“/> <birthTime been worth="1912“/> </subjectPersonn> </relatedSubject> </subject> <code code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking“/> <statusCode code="completed“/> <been worth xsi: type="BL" been worth="True“</been worth> </observation> 2.3.10 ADDICTION WITH ALCOHOL AND OTHER SUBSTANCES (CURRENT ALCOHOL/SUBSTANCE MISUSES) 18663-5 Section 18663-5 (CURRENT ALCOHOL/SUBSTANCE MISUSES). This section does not comprise coded entries. Addition of a bond with the person concerned. L Card Relative/element Attribute Been worth Comments ******************************************************** History off tobacco uses section v L Element of level 2 1 [0..1] section/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.1.9.10 PCC current alcohol/substance misuses section template 1 [1..1] section/code code 18663-5 Code identifying the section of dependences with alcohol and drug codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName HISTORY OFF PRESENT ALCOHOL AND/OR SUBSTANCE MISUSES 1 [1..1] section/text Contents readable by human of section (narrative part) 1 [1..1] section/ Titrate section readable by human: “dependence with alcohol and drug” Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part section is built. 2 [1..1] entry/observation classCode OBS Fixed by HL7 moodCode EVN Values fixed by HL7 3 [1..1] observation/templateId root ???? Alcohol/substance deceives observation template 3 [1..1] Observation/id root ‘’ extension ‘’ 3 [1..1] Observation/code code 160573003 codeSystem 2.16.840.1.113883.6.96 codeSystemName SNOMED-CT displayName Alcohol consumption 3 [1..1] Observation/statusCode code `completed ` 3 [1..1] Observation/effectiveTime Been worth Low Been worth High 3 [1..1] Been worth observation/ Xsi: type `ST' 1 glasses/day been worth 2 glasses/day 3 glasses/day not Subject participation used to link the alcohol/drug use observation to the pregnant episode 3 [0..1] ObservationentryRRelationShip typeCode SUBJ inversionInd “true” 4 [1..1] entryRRelationShip/observation classCode `OBS ` moodCode “EVN” 5 [1..1] Observation/templateId root 2.16.840.1.113883.10.20.1.41 Episode observation template Allows to model a addiction with the tobacco in bond with the episode of care pregnancy 4 [1..1] Observation/statusCode code `completed ` 4 [1..1] Observation/statusCode code `ASSERTION ` codeSystem 2.16.840.1.113883.5.4 4 [1..1] Been worth observation/ Xsi: type `CD ` Coding of the episode of care pregnancy code ????? codeSystem displayName Subject participation used yew the subject differs from the recordTarget off the header (e.g alcohol uses for the husband) 2 [0..1] Section/subject typeCode SUBJ 3 [0..1] Subject/relatedSubject classCode PRS 3 [1..1] relatedSubject/code code HUSB Coding with the HL7v3 vocabulary codeSystem 2.16.840.1.113883.5.111 codeSystemName RoleCode displayName “Husband” 4 [0..1] relatedSubject/SubjectPerson classCode PSN Extension HALF-VALUE LAYER R2 described in section family history of the CCC * is necessary it to name the spouse on this level or on the level of the header? 5 [0..1] SubjectPerson/name * 5 [0..1] SubjectPerson/birthTime been worth * 5 [0..1] SubjectPerson/administrativeGenderCode code M codeSystem 2.16.840.1.113883.5.111 codeSystemName administrativeGender displayName Male ******************************************************** History off alcohol uses section ******************************************************** --> <component> <section> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.1.9.10“/> <! -History off tobacco uses section template --> <code code="18663-5" codeSystem="2.16.840.1.113883.6.1“/> <[[title]]>Addiction with the tobacco</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT>Addiction with alcohol</HT><HT> Dates</HT></tr> </thead> <tbody> <tr><td>Before pregnancy</td><td>1 glass per day</td><td>1947 - 1972</td></tr> <tr>After pregnancy<td>"</td><td>Nun</td><td>1973 - </td></tr></p><p></tbody> </count> </text> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="?????“/> <! -History off alcohol uses observation template --> <id root= " “/> <code code="160573003" codeSystem="2.16.840.1.113883.6.96" displayName="alcohol consumption“/> <statusCode code="completed“/> <effectiveTime><low been worth="1947“/><high been worth="1972“/></effectiveTime> <been worth xsi: type="ST“>1 glass per day</been worth> </observation> </entry> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="????“/> <! -History off alcohol uses observation template --> <id root= " “/> <code code="160573003" codeSystem="2.16.840.1.113883.6.96" displayName=" alcohol consumption “/> <statusCode code="completed“/> <effectiveTime><low been worth="1973“/></effectiveTime> <been worth xsi: type="ST“>Nun</been worth> <entryRelationship typeCode="SUBJ" inversionInd="true“> <observation classCode="OBS" moodCode="EVN“> <templateId root="2.16.840.1.113883.10.20.1.41“/> <! -- Episode observation template --> <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4“/> <statusCode code="completed“/> <been worth xsi: type="CD" code="????" codeSystem="2.16.840.1.113883.6.96" displayName="Pregnancy“> </been worth> <entryRelationship typeCode="SAS“> <observation classCode="OBS" moodCode="EVN“> <id root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1“/> <code code="160573003" codeSystem="2.16.840.1.113883.6.96" displayName=" alcohol consumption “/> </observation> </entryRelationship> </observation> </entryRelationship> </observation> </entry> <entry typeCode="DRIV“> <observation classCode="OBS" moodCode="EVN“> <templateId root="?????“/> <! -History off alcohol uses observation template --> <id root= " “/> <subject> typeCode ="SBJ“> <relatedSubject classCode="PRS“> <code code="HUSB" codeSystem="2.16.840.1.113883.5.111" codeSystemName = " RoleCode “ displayName="Husband“/> <subjectPersonn> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male“/> <birthTime been worth="1912“/> </subjectPersonn> </relatedSubject> </subject> <code code="160573003" codeSystem="2.16.840.1.113883.6.96" displayName=" alcohol consumption “/> <statusCode code="completed“/> <been worth xsi: type="BL" been worth="True“</been worth> </observation> </entry> </section> </component> 2.3.11 PROGRESS NOTES 18733-6</p><p>L Card Relative/element Attribute Been worth Comments v L Element of level 2 1 [0..1] section/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.1.13.2.7 PCC Progress Notes section template 1 [1..1] section/code code 18733-6 Code identifying the section of the immunizations. codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC displayName SUBSEQUENT EVALUATION NOTES (ATTENDING PHYSICIAN) 1 [1..1] section/ Titrate section readable by human: “Sérodiagnostics at the end of the pregnancy” 1 [1..1] section/text Contents readable by human of the section (left narrative) Elements of level 3 1 [0. .n] section/entry typeCode DRIV Described the way in which the narrative part of the section is built. 2 [1..1] entry/organizer moodCode EVN Fixed by HL7 classCode CLUSTER Values fixed by HL7 3 [1..1] organizer /templateId root OID RSN followed by the identifier of Organizer Immunization Template the organizer gathering serologies 3 [0..1] organizer /id root extension 3 [1..1] organizer /code code IMMUNIZ Nomenclature used to code serology codeSystem 2.16.840.1.113883.5.4 codeSystemName ActCode displayName 3 [1..1] organizer /statusCode `completed' Contents of the organizer “sérodiagnostics”</p><p>3 [1…*] organizer /component typeCode COMP</p><p>4 [1..1] /observation component classCode OBS moodCode EVN 5 [0..1] /templateId observation root 1.3.6.1 .4.1.19376.1.5.3.1.4.13 Simple PCC observationTemplateId 5 [1..1] /code observation code Coding of serology (with the CIM10?) : rubella, syphilis, HIV, etc or codeSystem 2.16.840.1.113883.6.3 definition of a local code system to codeSystemName CIM10 code the sérodiagnostics displayName 5 [1..1] /statusCode observation code “completed” 5 [0..1] /value observation Xsi: type CD If serology is coded via a local nomenclature. Cf lists nomenclatures used for this code SERO1, SER2,… SERO5 code Value of the code Use of the NullFlavor attribute in the case where the sérodiagnostic is unknown: code been worth NullFlavor= “UNK” codeSystem OID RSN Identification of the system of coding of nomenclature codeSystemName DPERINAT RSN displayName The observation is possibly in relation to another observation (case of the hépatiteB) 5 [0..1] Observation/relationShip classCode REFR moodCode EVN 6 [0..1] /templateId observation root 1.3.6.1 .4.1.19376.1.5.3.1.4.13 Simple PCC observationTemplateId 6 [1..1] /code observation code Coding of ac and Ag C and E in the case of the hépatiteB codeSystem OID RSN followed by the classification of nomenclature SERO6 codeSystemName SERO6 displayName 6 [1..1] /statusCode observation code “completed” Serology is possibly in connection with an age gestationnel 5 [0..1] /entryRelationship observation typeCode SUBJ</p><p>6 [1..1] entryRelationship/observation moodCode EVN Fixed by HL7 classCode OBS 6 [0..1] observation/templateId root 1.3.6.1 .4.1.19376.1.5.3.1.4.13 Conform PCC 1.3.6.1 .4.1.19376.1.5.3.1.4.13.5 6 [1..1] observation/code code 11884-4 Coding of the data age gestationnel codeSystem 2.16.840.1.113883.6.1 codeSystemName LOINC</p><p> displayName GESTATIONAL AGE-TIME-PT-^FETUS-QN- CLINICAL.ESTIMATED 6 [1..1] observation/codeStatus code `completed' 6 [1..1] been worth observation/ xsi: type PQ been worth Value in weeks SERO1 Code the wording 1 negative 2 positive SERO2 Code the wording 1 Not immunized 2 immunized 3 seroconversion SERO3 Code the wording 1 negative 2 Ac VHc+ SERO4 Code the wording 1 IgG- 2 IgH+ SERO5 Code the wording 1 AgHBs- 2 AgHBs+ 3 AcHBs+ SERO6 Code the wording 1 AgHBc+ 2 AcHBc+ 3 AgHBe+ 3 AcHBe+ ******************************************************** Immunizations section ******************************************************** --> <component> <section> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.1.13.2.7“/> <! -Progress Notes section template --> <code code="11369-6" codeSystem="2.16.840.1.113883.6.1“/> <[[title]]>Serology</[[title]]> <text> <count to border="1" width="100%“> <thead> <tr><HT>Infectious agent</HT><HT>Date</HT><HT>Statute</HT></tr> </thead> <tbody> <tr><td>Rubella</td><td>Nov. 1999</td><td>Completed</td></tr> <tr><td>Syphilis</td><td>DEC 1998</td><td>Completed</td></tr> <tr><td>Hepatitis B</td><td>DEC 1998</td><td>Completed</td></tr> </tbody> </count> </text> <entry typeCode="DRIV“> <organizer classCode="CLUSTER" moodCode="EVN“> <templateId root="OID Immunizations organizer within community RSN“/> <! -Immunizations organizer template --> <id root= " “/> <statusCode code="completed“/> <code code="IMMUNIZ" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode" displayName= " “/> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <id root= " “ extension= " “ /> <code code="Rubella-code" codeSystem="2.16.840.1.113883.6.3" codeSystemName="CIM10” displayName="Rubella“/> <statusCode code="completed“/> <code code="SERO1" codeSystem="OID RSN nomenclature SERO1 " codeSystemName="RSN” <been worth xsi: type="CD" been worth="1“/> </observation> </component> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <id root= " “ extension= " “ /> <code code="Syphilis-code" codeSystem="2.16.840.1.113883.6.3" codeSystemName="CIM10” displayName="Syphilis“/> <statusCode code="completed“/> <code code="SERO2" codeSystem="OID RSN nomenclature SERO2 " codeSystemName="RSN” <been worth xsi: type="CD" been worth="1“/> </observation> </component> <component typeCode="COMP“ > <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <id root= " “ extension= " “ /> <code code="HepatitisB-code" codeSystem="2.16.840.1.113883.6.3" codeSystemName="CIM10” displayName="HepatitisB“/> <statusCode code="completed“/> <code code="SERO5" codeSystem="OID RSN nomenclature SERO5 " codeSystemName="SERO5” <been worth xsi: type="CD" been worth="2“/> <entryRelationship typeCode="REFR“> <observation classCode="OBS" moodCode="EVN“> <templateId root="1.3.6.1 .4.1.19376.1.5.3.1.4.13“/> <! -- Result observation template --> <code code="1" codeSystem=" OID RSN nomenclature SERO6" codeSystemName="SERO6” displayName="AgHBc+“/> </entryRelationship> </observation> </component> </organizer> </entry> </section> </component></p><p>[1] HALF-VALUE LAYER r2: Clinical Document Structures release2 [2] Definition of at the head the HALF-VALUE LAYER French r2-Specifications</p>