Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS https://s.details.loinc.org/LOINC/74028-2.html?sections=Comprehensive
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| Section Heading or Element | OBX-2 DataType | OBX-3 Observation Identifier component | OBX-3 Text component | OBX-3 Value | OBX-4 Observation sub-ID | Suggested OBX-5 Observation value or Value Set or Constraint | OBX-14 Date/time of the observation | OCCURENCES | VMR DATATYPE |
|---|---|---|---|---|---|---|---|---|---|
| Report template ID | RP | 74028-2 | Report template ID | 1 | HL7V2-VMR.v1^HL7V2 VMR&99A-9AAC5A649D18B6F2&L^TX^Octet-stream | 1 | ENTRY | ||
| History of Presenting Complaint | CWE | 73983-9 | 73983-9^^LN | 1.1 | 34046-3^History of Presenting Complaint^LN | 0..1 | SECTION | ||
| Chief Complaint | CWE | 10154-3 | Chief Complaint | 10154-3^Chief 3^Chief Complaint^LN | 1.1.1 | Constraint (Child of Snomed-CT term 404684003 | Clinical finding (finding)) | 0..1 | CODEDVALUE | |
| Date of Onset | TS | 11368-8 | Date of Onset | 11368-8^Date 8^Date of Onset^LN | 1.1.2 | 0..1 | DATETIME | ||
| Notes | FT | 8251-1 | Notes | 8251-1^Notes^LN1^Notes^LN | 1.1.3 | 0..1 | STRING | ||
| History of Past Illness | CWE | 73983-9 | 73983-9^^LN | 1.2 | 11348-0^History of Past Illness^LN^417662000^History of Past Illness^SCT | 0..1 | SECTION | ||
| Past Illness† | - | 1.2.1.RepeatOf[CLUSTER -- Past Illness] | 0..* | STRUCTURAL | |||||
| Past Illness | CWE | 11349-8 | Past Illness | 11349-8^Past 8^Past Illness^LN | 1.2.1.RepeatOf[CLUSTER -- Past Illness].1 | Constraint (Child of Snomed-CT term 404684003 | Clinical finding (finding)) | 0..1 | CODEDVALUE | |
| Temporal Context | CWE | 408731000 | Temporal Context | 408731000^Temporal 408731000^Temporal Context^SCT | 1.2.1.RepeatOf[CLUSTER -- Past Illness].2 | Value Set ( 15240007^Current^SCT 410511007^Current or past^SCT 410587003^Past - specified^SCT 410588008^Past - unspecified^SCT 410589000^All times past^SCT 6493001^Recent^SCT )
If the temporal context is unspecified, then 410511007^Current or past^SCT is the assumed value. | 0..1 | CODEDVALUE | |
| Illness Dates | DR | 11368-8 | Illness Dates | 11368-8^Illness 8^Illness Dates^LN | 1.2.1.RepeatOf[CLUSTER -- Past Illness].3 | 0..1 | DATERANGE | ||
| Notes on Illness | FT | 8251-1 | Notes on Illness | 8251-1^Notes 1^Notes on Illness^LN | 1.2.1.RepeatOf[CLUSTER -- Past Illness].4 | 0..1 | STRING | ||
| Procedures | CWE | 73983-9 | 73983-9^^LN | 1.3 | 47519-4^^LN^416940007 | 0..1 | SECTION | ||
| Procedure† | - | 71388002^Procedure^SCT | 71388002^Procedure^SCT | 1.3.1.RepeatOf[CLUSTER -- Procedure] | 0..* | STRUCTURAL | |||
| Procedure Performed | CWE | 29300-1 | Procedure Performed | 29300-1^Procedure 1^Procedure Performed^LN | 1.3.1.RepeatOf[CLUSTER -- Procedure].1 | Constraint (Child of Snomed-CT term 71388002 | Procedure (procedure) |) | Y | 0..1 | CODEDVALUE |
| Notes on Procedure | FT | 8251-1 | Notes on Procedure | 8251-1^Notes 1^Notes on Procedure^LN | 1.3.1.RepeatOf[CLUSTER -- Procedure].2 | 0..1 | STRING | ||
| Family History | CWE | 73983-9 | 73983-9^^LN | 1.4 | 10157-6^Family History^LN | 0..1 | SECTION | ||
| Patients Family Tree ID | ST | 74027-4 | Patients Family Tree ID | 74027-4^Patients 4^Patients Family Tree ID^LN | 1.4.1 | 0..1 | STRING | ||
| Natural Father ID | ST | 74026-6 | Natural Father ID | 74026-6^Natural 6^Natural Father ID^LN | 1.4.2 | 0..1 | STRING | ||
| Natural Mother ID | ST | 74025-8 | Natural Mother ID | 74025-8^Natural 8^Natural Mother ID^LN | 1.4.3 | 0..1 | STRING | ||
| Relatives | CWE | 73983-9 | 73983-9^^LN | 1.4.4 | 224086007^Relatives^SCT | 0..1 | SECTION | ||
| Relative† | - | 1.4.4.1.RepeatOf[CLUSTER -- Relative] | 0..* | STRUCTURAL | |||||
| Relative Name | ST | 54138-3 | Relative Name | 54138-3^Relative 3^Relative Name^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].1 | 0..1 | STRING | ||
| Relationship | CWE | 44767-2 | Relationship | 44767-2^Relationship^LN2^Relationship^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].2 | Constraint (HL7 v3 FamilyMember Value set = Child of Role Code _PersonalRelationshipRoleType FAMMEMB) Use "ROLECODE" for Name of Coding System component of CWE See Table HL7 v3 FamilyMember Value set below | 0..1 | CODEDVALUE | |
| Relative ID | ST | 74024-1 | Relative ID | 74024-1^Relative 1^Relative ID^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].3 | 0..1 | STRING | ||
| Natural Father ID | ST | 74026-6 | Natural Father ID | 74026-6^Natural 6^Natural Father ID^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].4 | 0..1 | STRING | ||
| Natural Mother ID | ST | 74025-8 | Natural Mother ID | 74025-8^Natural 8^Natural Mother ID^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].5 | 0..1 | STRING | ||
| deceasedEstimatedAge | ST | 39016-1 | deceasedEstimatedAge | 39016-1^Deceased 1^Deceased Estimated Age^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].6 | 0..1 | REAL | ||
| LivingEstimatedAge | ST | LivingEstimatedAge | 21612-7^Living 7^Living Estimated Age^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].7 | 0..1 | REAL | |||
| Clinical Genomic Choice | CWE | 74042-3 | Clinical Genomic Choice | 73983-9^^LN9^^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice] | 0..* | COLLECTION | ||
| Clinical Observation | CWE | 74023-3 | Clinical Observation | 74023-3^Clinical 3^Clinical Observation^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].1 | 1..1 | CODEDVALUE | ||
| Negation Indicator | CWE | 74022-5 | Negation Indicator | 74022-5^Negation 5^Negation Indicator^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].2 | 0..1 | BOOLEAN | ||
| Cause of Death | CWE | 74044-9 | Cause of Death | 74044-9^Cause 9^Cause of Death^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].3 | 0..1 | BOOLEAN | ||
| DataEstimatedAge | ST | 21611-9 | DataEstimatedAge | 21611-9^Data 9^Data Estimated Age^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].4 | 0..1 | REAL | ||
| Genetic Loci | ST | 48018-6 | Genetic Loci | 48018-6^Genetic 6^Genetic Loci^LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].5.RepeatOf[ELEMENT -- Genetic Loci] | 0..* | STRING | ||
| Genetic Risks | CWE | 73983-9 | 73983-9^^LN | 1.4.5 | 106221001^Genetic Risks^SCT | 0..1 | SECTION | ||
| Pedigree Analysis Results † | - | 47708004^Pedigree Analysis Results^SCT | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results] | 0..* | STRUCTURAL | ||||
| Genetic Disease Assessed | CWE | 51967-8 | Genetic Disease Assessed | 51967-8^Genetic 8^Genetic Disease Assessed^LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].1 | 0..1 | CODEDVALUE | ||
| Input Parameters | CWE | 73983-9 | 73983-9^^LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2 | 73983-9^Input Parameters^LN | 0..1 | SECTION | ||
| Genetic Algorithm Used | CWE | 74021-7 | Genetic Algorithm Used | 74021-7^Genetic 7^Genetic Algorithm Used^LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.1 | 0..1 | CODEDVALUE | ||
| Sensitivity | NM | 74020-9 | Sensitivity | 74020-9^Sensitivity^LN9^Sensitivity^LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.2 | 0..1 | PHYSICALQUANTITY | ||
| Probability of Disease | ST | 74019-1 | Probability of Disease | 74019-1^Probability 1^Probability of Disease^LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].3.RepeatOf[ELEMENT -- Probability of Disease] | 0..* | REAL | ||
| Pregnancy History | CWE | 73983-9 | 73983-9^^LN | 1.5 | 11449-6^Pregnancy History^LN | 0..1 | SECTION | ||
| Gravida | NM | 11996-6 | Gravida | 11996-6^Gravida^LN6^Gravida^LN | 1.5.1 | 0..1 | INTEGER | ||
| Parity | NM | 11977-6 | Parity | 11977-6^Parity^LN6^Parity^LN | 1.5.2 | 0..1 | INTEGER | ||
| Miscarriages | NM | 11614-5 | Miscarriages | 11614-5^Miscarriages^LN5^Miscarriages^LN | 1.5.3 | 0..1 | INTEGER | ||
| Terminations | NM | 11613-7 | Terminations | 11613-7^Terminations^LN7^Terminations^LN | 1.5.4 | 0..1 | INTEGER | ||
| Social History | CWE | 73983-9 | 73983-9^^LN | 1.6 | 29762-2^Social History^LN | 0..1 | SECTION | ||
| Social Situation | FT | 10166-7 | Social Situation | 10166-7^Social 7^Social Situation^LN | 1.6.1 | 0..1 | STRING | ||
| Substance Use | CWE | 73983-9 | 73983-9^^LN | 1.7 | 18663-5^Substance Use^LN | 0..1 | SECTION | ||
| Smoking History | CWE | 73983-9 | 73983-9^^LN | 1.7.1 | 11367-0^Smoking History^LN | 0..1 | SECTION | ||
| Tobacco use and exposure | CWE | 63638-1 | Tobacco use and exposure | 1136763638-0^Tobacco 1^Tobacco use and exposure^LN | 1.7.1.1 | Value Set ( 8517006^Ex-smoker^SCT 43381005^Passive smoker^SCT 77176002^Smoker^SCT 8392000^Non-smoker^SCT ) | 0..1 | CODEDVALUE | |
| Tobacco smoking consumption | NM | 63858-5 | Tobacco smoking consumption | 63858-5^Tobacco 5^Tobacco smoking consumption^LN | 1.7.1.2 | 0..1 | PHYSICALQUANTITY | ||
| Lifetime Intake | NM | 74011-8 | Lifetime Intake | 74011-8^Lifetime 8^Lifetime Intake^LN | 1.7.1.3 | 0..1 | PHYSICALQUANTITY | ||
| Date Ceased | DT | 74010-0 | Date Ceased | 74010-0^Date 0^Date Ceased^LN | 1.7.1.4 | 0..1 | DATETIME | ||
| Alcohol Intake | CWE | 73983-9 | 73983-9^^LN | 1.7.2 | 11330-8^Alcohol Intake^LN | 0..1 | SECTION | ||
| Alcohol Intake | CWE | 11331-6 | Alcohol Intake | 11331-6^Alcohol 6^Alcohol Intake^LN | 1.7.2.1 | Value Set ( 82581004^Ex-drinker^SCT 105542008^Non - drinker^SCT 219006^Current drinker^SCT ) | 0..1 | CODEDVALUE | |
| Last Drank Alcohol | DT | 74014-2 | Last Drank Alcohol | 74014-2^Last 2^Last Drank Alcohol^LN | 1.7.2.2 | 0..1 | DATETIME | ||
| 30 day quantity and frequency | CWE | 73983-9 | 73983-9^^LN | 1.7.2.3 | 030301^30 day quantity and frequency^PHENX | 0..1 | SECTION | ||
| Number of days alcohol consumed | NM | 63597-9 | Number of days alcohol consumed | 63597-9^Number 9^Number of days alcohol consumed^LN | 1.7.2.3.1 | 0..1 | INTEGER | ||
| Standard drinks per day on a drinking day in last 30 days | NM | 63598-7 | Standard drinks per day on a drinking day in last 30 days | 63598-7^Standard 7^Standard drinks per day on a drinking day in last 30 days^LN | 1.7.2.3.2 | 0..1 | INTEGER | ||
| Average Daily Alcohol Intake | NM | 74013-4 | Average Daily Alcohol Intake | 74013-4^Average 4^Average Daily Alcohol Intake^LN | 1.7.2.4 | 0..1 | PHYSICALQUANTITY | ||
| Maximum Daily Standard Drinks | NM | 63591-2 | Maximum Daily Standard Drinks | 63591-2^Maximum 2^Maximum Daily Standard Drinks^LN | 1.7.2.5 | 0..1 | PHYSICALQUANTITY | ||
| Years Alcohol Consumed | NM | 74012-6 | Years Alcohol Consumed | 74012-6^Years 6^Years Alcohol Consumed^LN | 1.7.2.6 | 0..1 | PHYSICALQUANTITY | ||
| Alcohol abuse or dependence (eg DSM IV) | CWE | 74043-1 | Alcohol abuse or dependence (eg DSM IV) | 74043-1^Alcohol 1^Alcohol abuse or dependence (eg DSM IV)^LN | 1.7.2.7 | 0..1 | BOOLEAN | ||
| Other substance Use | CWE | 73983-9 | 73983-9^^LN | 1.7.3 | 11342-3^Other substance Use^LN | 0..1 | SECTION | ||
| Drug misuse details | CWE | 228366006 | Drug misuse details | 228366006^Drug 228366006^Drug misuse details^SCT | 1.7.3.1.RepeatOf[ELEMENT -- Drug misuse details] | Value Set ( 428659002^Amphetamine misuse^SCT 429179002^Antidepressant misuse^SCT 428623008^Barbiturate misuse^SCT 428823006^Cannabis misuse^SCT 429782000^Cocaine misuse^SCT 307052004^Illicit drug use^SCT 228376009^Inhales drugs^SCT 226034001^Injecting drug user^SCT 70545002^Narcotic drug user^SCT 105546006^Occasional drug abuser^SCT 228372006^Poly-drug misuser^SCT 428495004^Solvent misuse^SCT 228381000^Sniffs drugs^SCT 429512006^Methadone misuse^SCT ) | 0..* | CODEDVALUE | |
| Exercise History | CWE | 73983-9 | 73983-9^^LN | 1.8 | 266930008^Exercise History^SCT | 0..1 | SECTION | ||
| Currently Exercising | CWE | 74008-4 | Currently Exercising | 74008-4^Currently Exercising^LN4^Exercise intensity^LN | 1.8.1 | Value Set ( 160635005^Exercise grading unknown^SCT 160633003^Enjoys heavy exercise^SCT 160645007^Enjoys intermediate exercise^SCT 228446001^Gets little exercise^SCT 228445002^Gets no exercise^SCT 160631001^Enjoys light exercise^SCT 160632008^Enjoys moderate exercise^SCT 102533007^Excessive exercise^SCT ) | 0..1 | CODEDVALUE | |
| Exercise Type | CWE | 73986-2 | Exercise Type | 55410-5^Exercise Type^LN | 1.8.2 | Value Set ( 229072005^Aerobic^SCT ) | 0..1 | CODEDVALUE | |
| Time Spent Exercising | NM | 74009-2 | Time Spent Exercising | 74009-2^Time 2^Time Spent Exercising^LN | 1.8.3 | 0..1 | PHYSICALQUANTITY | ||
| Vitals | CWE | 73983-9 | 73983-9^^LN | 1.9 | 8716-3^Vitals^LN | 0..1 | SECTION | ||
| Blood Pressure | CWE | 73983-9 | 73983-9^^LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure] | 55417-0^Blood Pressure^LN | 0..* | COLLECTION | ||
| Systolic Pressure | NM | 8480-6 | Systolic Pressure | 8480-6^Systolic 6^Systolic Pressure^LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure].1 | Y | 0..1 | PHYSICALQUANTITY | |
| Diastolic Pressure | NM | 8462-4 | Diastolic Pressure | 8462-4^Diastolic 4^Diastolic Pressure^LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure].2 | 0..1 | PHYSICALQUANTITY | ||
| Patient Position | CWE | 8361-8 | Patient Position | 8361-8^Patient 8^Patient Position^LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure].3 | Value Set ( 33586001^Sitting^SCT 102538003^Lying^SCT 272580008^Semi-recumbent^SCT 10904000^Standing^SCT ) | 0..1 | CODEDVALUE | |
| Pulse rate | NM | 8893-0 | Pulse rate | 8893-0^Pulse 0^Pulse rate^LN | 1.9.2.RepeatOf[ELEMENT -- Pulse rate] | Y | 0..* | PHYSICALQUANTITY | |
| Weight | NM | 29463-7 | Weight | 29463-7^Weight^LN7^Weight^LN | 1.9.3.RepeatOf[ELEMENT -- Weight] | Y | 0..* | PHYSICALQUANTITY | |
| BMI | NM | 39156-5 | BMI | 39156-5^BMI^LN5^BMI^LN | 1.9.4.RepeatOf[ELEMENT -- BMI] | Y | 0..* | PHYSICALQUANTITY | |
| Oxygen Saturation | NM | 59408-5 | Oxygen Saturation | 59408-5^Oxygen 5^Oxygen Saturation^LN | 1.9.5.RepeatOf[ELEMENT -- Oxygen Saturation] | Y | 0..* | PHYSICALQUANTITY | |
| Height | NM | 8302-2 | Height | 8302-2^Height^LN2^Height^LN | 1.9.6.RepeatOf[ELEMENT -- Height] | Y | 0..* | PHYSICALQUANTITY | |
| Temperature | NM | 8310-5 | Temperature | 8310-5^Temperature^LN5^Temperature^LN | 1.9.7.RepeatOf[ELEMENT -- Temperature] | Y | 0..* | PHYSICALQUANTITY | |
| Respiratory rate | NM | 9279-1 | Respiratory rate | 9279-1^Respiratory 1^Respiratory rate^LN | 1.9.8.RepeatOf[ELEMENT -- Respiratory rate] | 0..* | PHYSICALQUANTITY | ||
| Alerts | CWE | 73983-9 | 73983-9^^LN | 1.10 | 44944-7^Alerts^LN | 0..1 | SECTION | ||
| Alert | - | 1.10.1.RepeatOf[CLUSTER -- Alert] | 0..* | STRUCTURAL | |||||
| Alert Type | CWE | 74018-3 | Alert Type | 74018-3^Alert 3^Alert Type^LN | 1.10.1.RepeatOf[CLUSTER -- Alert].1 | Value Set ( 129697009^Psychosocial^SCT 307824009^Administrative^SCT 281694009^Clinical^SCT 102487004^Environmental^SCT 78648007^Infection risk^SCT 405145004^Safety and security^SCT 363871006^Special Mental Health^SCT 315638005^Special needs and/or preferences^SCT ) | 0..1 | CODEDVALUE | |
| Active | CWE | 74017-5 | Active | 74017-5^Active^LN5^Active^LN | 1.10.1.RepeatOf[CLUSTER -- Alert].2 | 0..1 | BOOLEAN | ||
| Specific Alert | CWE | 44944-7 | Specific Alert | 44944-7^Specific 7^Specific Alert^LN | 1.10.1.RepeatOf[CLUSTER -- Alert].3 | Suggested Value Set ( 40739000^Has difficulty swallowing^SCT 224331001^Known to police^SCT 224347004^Has enduring power of attorney^SCT 310301000^Has advance health directive^SCT ) | 0..1 | CODEDVALUE | |
| Reported by | CWE | Reported by | 48766-0^Reported 0^Reported by^LN | 1.10.1.RepeatOf[CLUSTER -- Alert].4 | Value Set ( 116154003^Subject of care^SCT 229774002^Carer^SCT 223366009^Health worker^SCT 307982007^Social services provider^SCT 14406004^Police^SCT 303071001^Family member^SCT 113163005^Friend^SCT ) | 0..1 | CODEDVALUE | ||
| Recorded date | DT | Recorded date | 74015-9^Recorded 9^Recorded date^LN | 1.10.1.RepeatOf[CLUSTER -- Alert].5 | 0..1 | DATETIME |
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