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draft Template  Vital Signs Observation

Id 1.3.6.1.4.1.19376.1.5.3.1.4.13.2 Effective Date 2013‑12‑20
Status draft Draft Version Label
Name EntryVitalSignsObservation Display Name Vital Signs Observation
Description

A vital signs observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

Note: Although interpretationCode, methodCode and targetSiteCode are foreseen by the parent template, and initially introduced also in the epSOS template, they are not supposed to be actually used in this version since they were not included in the functional specifications and therefore not validated from a functional point of view. Those element have been retained as optional elements, without vocabulary binding defined, only for future consideration.  


Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.13.2
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 2 concepts
Id Name Data Set
epsos-dataelement-121 draft Diastolic Blood Pressure draft epSOS Data Set
epsos-dataelement-120 draft Systolic Blood Pressure draft epSOS Data Set
Used by / Uses
Used by 0 transactions and 5 templates, Uses 0 templates
Used by as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.13.1 Containment draft Vital Signs Organizer 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 link draft Section Coded Vital Signs 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link draft epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link draft epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link draft epSOS-Medication Related Overview 2013‑12‑20
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>  <templateId root="2.16.840.1.113883.10.20.1.31"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.2"/>  <id root=" " extension=" "/>  <code code=" " codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#xxx"/>  </text>  <statusCode code="completed"/>  <effectiveTime value=" "/>  <repeatNumber value=" "/>  <value xsi:type="PQ" value=" " unit=" "/>  <interpretationCode code=" " codeSystem=" " codeSystemName=" "/>  <methodCode code=" " codeSystem=" " codeSystemName=" "/>  <targetSiteCode code=" " codeSystem=" " codeSystemName=" "/></observation>
notice There is an open issue with this item:
Item DT Card Conf Description Label
hl7:observation
 1 … 1 R (Entdotsion)
hl7:templateId
 II.EPSOS 1 … 1 M (Entdotsion)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:templateId
 II.EPSOS 1 … 1 M (Entdotsion)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.31
hl7:templateId
 II.EPSOS 1 … 1 M (Entdotsion)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13.2
hl7:id
 II 0 … * R (Entdotsion)
hl7:code
 CE.EPSOS 1 … 1 M

A vital signs observation entry shall use one of the following LOINC codes, with the specified data types and units.

LOINC Display Name Unit Datatype
8480-6 INTRAVASCULAR SYSTOLIC mm[Hg] PQ
8462-4 INTRAVASCULAR DIASTOLIC mm[Hg] PQ

(Entdotsion)
 
target
epsos-dataelement-121 draft Diastolic Blood Pressure draft epSOS Data Set
epsos-dataelement-120 draft Systolic Blood Pressure draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.21 epSOSBloodPressure (DYNAMIC)
hl7:text
 ED 0 … 1 R (Entdotsion)
hl7:reference
 TEL 1 … 1 M (Entdotsion)
@value
 1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 CS 1 … 1 M (Entdotsion)
@code
 CONF 1 … 1 F completed
hl7:effectiveTime
 TS 1 … 1 R Date when the measurement was done.
This date shall be the same as the effective time for the Vital Signs organizer element. 		(Entdotsion)
  Example <effectiveTime value="20180327"/>
hl7:value
 PQ 1 … 1 R

The <value> element shall be present, and shall be of the appropriate data type specified for measure in the table above.

(Entdotsion)
  CONF
@unit is "mm[Hg]"
hl7:interpretationCode
 CE 0 … * R

The interpretation code may be present to provide an interpretation of the vital signs measure (e.g., High, Normal, Low, et cetera).

Not expected to be used in this version of the Patient Summary, retained as optional elements, without vocabulary binding defined, only for future consideration.  


(Entdotsion)
hl7:methodCode
 CE 0 … * R

The <methodCode> element may be present to indicate the method used to obtain the measure. Note that method used is distinct from, but possibly related to the target site.

Not expected to be used in this version of the Patient Summary, retained as optional elements, without vocabulary binding defined, only for future consideration.

(Entdotsion)
hl7:targetSiteCode
 CD 0 … * R

The target site of the measure may be identified in the <targetSiteCode> element (e.g., Left arm [blood pressure], oral [temperature], et cetera).

Not expected to be used in this version of the Patient Summary, retained as optional elements, without vocabulary binding defined, only for future consideration.

(Entdotsion)