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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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3 Alternative Code component         
Section Heading or ElementOBX-2 DataTypeOBX-3 Observation Identifier componentOBX-3 Text componentOBX-3 Name of Coding System componentOBX-OBX-3 Name of Alternative Coding systemOBX-4 Observation sub-ID

Suggested

OBX-5 Observation value

or

Value Set or Constraint

OBX-14 Date/time of the observationOCCURENCESVMR DATATYPE
Report template IDRP74028-2Report template IDLN  1HL7V2-VMR.v1^HL7V2 VMR&99A-9AAC5A649D18B6F2&L^TX^Octet-stream 1ENTRY
History of Presenting ComplaintCWE73983-9 LN  1.134046-3^History of Presenting Complaint^LN 0..1SECTION
Chief ComplaintCWE10154-3Chief ComplaintLN33962009SCT1.1.1Constraint (Child of Snomed-CT term 404684003 | Clinical finding (finding)) 0..1CODEDVALUE
Date of OnsetTS11368-8Date of OnsetLN298059007SCT1.1.2  0..1DATETIME
NotesFT8251-1NotesLN  1.1.3  0..1STRING
History of Past IllnessCWE73983-9 LN  1.211348-0^History of Past Illness^LN^417662000^History of Past Illness^SCT 0..1SECTION
Past Illness†-    1.2.1.RepeatOf[CLUSTER -- Past Illness]  0..*STRUCTURAL
Past IllnessCWE11349-8Past IllnessLN404684003SCT1.2.1.RepeatOf[CLUSTER -- Past Illness].1Constraint (Child of Snomed-CT term 404684003 | Clinical finding (finding)) 0..1CODEDVALUE
Temporal ContextCWE408731000Temporal ContextSCT  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 this field is unvalued, then 410511007^Current or past^SCT is the assumed value.

 0..1CODEDVALUE
Illness DatesDR11368-8Illness DatesLN  1.2.1.RepeatOf[CLUSTER -- Past Illness].3  0..1DATERANGE
Notes on IllnessFT8251-1Notes on IllnessLN  1.2.1.RepeatOf[CLUSTER -- Past Illness].4  0..1STRING
ProceduresCWE73983-9 LN  1.347519-4^^LN^416940007 0..1SECTION
Procedure†-     1.3.1.RepeatOf[CLUSTER -- Procedure]  0..*STRUCTURAL
Procedure PerformedCWE29300-1Procedure PerformedLN  11.3.1.RepeatOf[CLUSTER -- Procedure].1Constraint (Child of Snomed-CT term 71388002 | Procedure (procedure) |)Y0..1CODEDVALUE
Notes on ProcedureFT8251-1Notes on ProcedureLN  1.3.1.RepeatOf[CLUSTER -- Procedure].2  0..1STRING
Family HistoryCWE73983-9 LN  1.410157-6^Family History^LN 0..1SECTION
Patients Family Tree IDST74027-4Patients Family Tree IDLN422549004SCT1.4.1  0..1STRING
Natural Father IDST74026-6Natural Father IDLN  1.4.2  0..1STRING
Natural Mother IDST74025-8Natural Mother IDLN  1.4.3  0..1STRING
RelativesCWE73983-9 LN  1.4.4224086007^Relatives^SCT 0..1SECTION
Relative†-     1.4.4.1.RepeatOf[CLUSTER -- Relative]  0..*STRUCTURAL
Relative NameST54138-3Relative NameLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].1  0..1STRING
RelationshipCWE44767-2RelationshipLN  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..1CODEDVALUE
Relative IDST74024-1Relative IDLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].3  0..1STRING
Natural Father IDST74026-6Natural Father IDLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].4  0..1STRING
Natural Mother IDST74025-8Natural Mother IDLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].5  0..1STRING
deceasedEstimatedAgeST39016-1deceasedEstimatedAgeLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].6  0..1REAL
LivingEstimatedAgeST LivingEstimatedAgeLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].7  0..1REAL
Clinical Genomic ChoiceCWE74042-3Clinical Genomic ChoiceLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice]  0..*COLLECTION
Clinical ObservationCWE74023-3Clinical ObservationLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].1  1..1CODEDVALUE
Negation IndicatorCWE74022-5Negation IndicatorLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].2  0..1BOOLEAN
Cause of DeathCWE74044-9Cause of DeathLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].3  0..1BOOLEAN
DataEstimatedAgeST21611-9DataEstimatedAgeLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].4  0..1REAL
Genetic LociST48018-6Genetic LociLN  1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].5.RepeatOf[ELEMENT -- Genetic Loci]  0..*STRING
Genetic RisksCWE73983-9 LN  1.4.5106221001^Genetic Risks^SCT 0..1SECTION
Pedigree Analysis Results †-     11.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results]  0..*STRUCTURAL
Genetic Disease AssessedCWE51967-8Genetic Disease AssessedLN  1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].1  0..1CODEDVALUE
Input ParametersCWE73983-9 LN  1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2^Input Parameters73983-9^Input Parameters^LN 0..1SECTION
Genetic Algorithm UsedCWE74021-7Genetic Algorithm UsedLN  1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.1  0..1CODEDVALUE
SensitivityNM74020-9SensitivityLN  1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.2  0..1PHYSICALQUANTITY
Probability of DiseaseST74019-1Probability of DiseaseLN  1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].3.RepeatOf[ELEMENT -- Probability of Disease]  0..*REAL
Pregnancy HistoryCWE73983-9 LN  1.5118185001^Pregnancy History^SCT11449-6^Pregnancy History^LN 0..1SECTION
GravidaNM11996-6GravidaLN161732006SCT1.5.1  0..1INTEGER
ParityNM11977-6ParityLN364325004SCT1.5.2  0..1INTEGER
MiscarriagesNM11614-5MiscarriagesLN248989003SCT1.5.3  0..1INTEGER
TerminationsNM11613-7TerminationsLN252114001SCT1.5.4  0..1INTEGER
Social HistoryCWE73983-9 LN  1.629762-2^Social History^LN^160476009^^SCTHistory^LN 0..1SECTION
Social SituationFT10166-7Social SituationLN  1.6.1  0..1STRING
Substance UseCWE73983-9 LN  1.7409069009^Substance Use^SCT18663-5^Substance Use^LN 0..1SECTION
Smoking HistoryCWE73983-9 LN  1.7.1365981007^Smoking History^SCT11367-0^Smoking History^LN 0..1SECTION
Tobacco use and exposureCWE63638-1Tobacco use and exposureLN229819007SCT1.1.7.1.1

Suggested Value Set (

8517006^Ex-smoker^SCT

 43381005^Passive smoker^SCT

77176002^Smoker^SCT

8392000^Non-smoker^SCT

)

 0..1CODEDVALUE
Tobacco smoking consumptionNM63858-5Tobacco smoking consumptionLN266918002SCT1.7.1.2  0..1PHYSICALQUANTITY
Lifetime IntakeNM74011-8Lifetime IntakeLN401201003SCT1.7.1.3  0..1PHYSICALQUANTITY
Date CeasedDT74010-0Date CeasedLN  1.7.1.4  0..1DATETIME
Alcohol IntakeCWE73983-9 LN  1.7.2228273003^Alcohol Intake^SCT11330-8^Alcohol Intake^LN 0..1SECTION
Alcohol IntakeCWE11331-6Alcohol IntakeLN160573003SCT1.7.2.1

Suggested Value Set (

82581004^Ex-drinker^SCT

105542008^Non - drinker^SCT

219006^Current drinker^SCT

)

 0..1CODEDVALUE
Last Drank AlcoholDT74014-2Last Drank AlcoholLN  1.7.2.2  0..1DATETIME
30 day quantity and frequencyCWE73983-9 LN  1.7.2.3030301^30 73983-9^30 day quantity and frequency^PHENXfrequency^LN 0..1SECTION
Number of days alcohol consumedNM63597-9Number of days alcohol consumedLN  1.7.2.3.1  0..1INTEGER
Standard drinks per day on a drinking day in last 30 daysNM63598-7Standard drinks per day on a drinking day in last 30 daysLN  11.7.2.3.2  0..1INTEGER
Average Daily Alcohol IntakeNM74013-4Average Daily Alcohol IntakeLN443315005SCT1.7.2.4  0..1PHYSICALQUANTITY
Maximum Daily Standard DrinksNM63591-2Maximum Daily Standard DrinksLN442547005SCT1.7.2.5  0..1PHYSICALQUANTITY
Years Alcohol ConsumedNM74012-6Years Alcohol ConsumedLN228330005SCT1.7.2.6  0..1PHYSICALQUANTITY
Alcohol abuse or dependence (eg DSM IV)CWE74043-1Alcohol abuse or dependence (eg DSM IV)LN15167005SCT1.7.2.7  0..1BOOLEAN
Other substance UseCWE73983-9 LN  1.7.3363908000^Other 11342-3^Other substance Use^SCTUse^LN 0..1SECTION
Drug misuse detailsCWE228366006Drug misuse detailsSCT  1.7.3.1.RepeatOf[ELEMENT -- Drug misuse details]

Suggested 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 HistoryCWE73983-9 LN  11.874008-4^Exercise History^LN^266930008^Exercise 266930008^Exercise History^SCT 0..1SECTION
Currently ExercisingCWE  74008-4Currently ExercisingLN  1.8.1

Suggested 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..1CODEDVALUE
Exercise TypeCWE73986-2Exercise TypeLN  1.8.2 

Suggested value Set (

229072005^Aerobic^SCT

)

 0..1CODEDVALUE
Time Spent ExercisingNM74009-2Time Spent ExercisingLN  1.8.3  0..1PHYSICALQUANTITY
VitalsCWE73983-9 LN  1.946680005^Vitals^SCT8716-3^Vitals^LN 0..1SECTION
Blood PressureCWE73983-9 LN  1.9.1.RepeatOf[CLUSTER -- Blood Pressure]55417-0^Blood Pressure^LN^75367002^Blood Pressure^SCT0^Blood Pressure^LN 0..*COLLECTION
Systolic PressureNM8480-6Systolic PressureLN  1.9.1.RepeatOf[CLUSTER -- Blood Pressure].1 Y0..1PHYSICALQUANTITY
Diastolic PressureNM8462-4Diastolic PressureLN  1.9.1.RepeatOf[CLUSTER -- Blood Pressure].2  0..1PHYSICALQUANTITY
Patient PositionCWE8361-8Patient PositionLN  1.9.1.RepeatOf[CLUSTER -- Blood Pressure].3

Suggested Value Set (

33586001^Sitting^SCT

102538003^Lying^SCT

272580008^Semi-recumbent^SCT

10904000^Standing^SCT

)

 0..1CODEDVALUE
Pulse rateNM8893-0Pulse rateLN  1.9.2.RepeatOf[ELEMENT -- Pulse rate] Y0..*PHYSICALQUANTITY
WeightNM29463-7WeightLN  1.9.3.RepeatOf[ELEMENT -- Weight] Y0..*PHYSICALQUANTITY
BMINM39156-5BMILN  1.9.4.RepeatOf[ELEMENT -- BMI] Y0..*PHYSICALQUANTITY
Oxygen SaturationNM59408-5Oxygen SaturationLN  1.9.5.RepeatOf[ELEMENT -- Oxygen Saturation] Y0..*PHYSICALQUANTITY
HeightNM8302-2HeightLN  1.9.6.RepeatOf[ELEMENT -- Height] Y0..*PHYSICALQUANTITY
TemperatureNM8310-5TemperatureLN  1.9.7.RepeatOf[ELEMENT -- Temperature] Y0..*PHYSICALQUANTITY
Respiratory rateNM9279-1Respiratory rateLN  1.9.8.RepeatOf[ELEMENT -- Respiratory rate]  0..*PHYSICALQUANTITY
AlertsCWE73983-9 LN  1.1044944-7^Alerts^LN 0..1SECTION
Alert -    1.10.1.RepeatOf[CLUSTER -- Alert]  0..*STRUCTURAL
Alert TypeCWE74018-3Alert TypeLN  1.10.1.RepeatOf[CLUSTER -- Alert].1

Suggested 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..1CODEDVALUE
ActiveCWE74017-5ActiveLN  1.10.1.RepeatOf[CLUSTER -- Alert].2  0..1BOOLEAN
Specific AlertCWE44944-7Specific AlertLN  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..1CODEDVALUE
Reported byCWE74015-9Reported byLN  1.10.1.RepeatOf[CLUSTER -- Alert].4

Suggested 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..1CODEDVALUE
Recorded dateDT Recorded date   1.10.1.RepeatOf[CLUSTER -- Alert].5  0..1DATETIME

...