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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

...

Section Heading or ElementOBX-2 DataTypeOBX-3 Observation Identifier componentOBX-3 Text componentOBX-3 Name of Coding System componentOBX-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 IDLN1HL7V2-VMR.v1^HL7V2 VMR&99A-9AAC5A649D18B6F2&L^TX^Octet-stream 1ENTRY
History of Presenting ComplaintCWE73983-9 LN1.134046-3^History of Presenting Complaint^LN 0..1SECTION
Chief ComplaintCWE10154-3Chief ComplaintLN1.1.1Constraint (Child of Snomed-CT term 404684003 | Clinical finding (finding)) 0..1CODEDVALUE
Date of OnsetTS11368-8Date of OnsetLN1.1.2  0..1DATETIME
NotesFT8251-1NotesLN1.1.3  0..1STRING
History of Past IllnessCWE73983-9 LN1.211348-0^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 IllnessLN1.2.1.RepeatOf[CLUSTER -- Past Illness].1Constraint (Child of Snomed-CT term 404684003 | Clinical finding (finding)) 0..1CODEDVALUE
Temporal ContextCWE408731000Temporal ContextSCT1.2.1.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 DatesLN1.2.1.RepeatOf[CLUSTER -- Past Illness].3  0..1DATERANGE
Notes on IllnessFT8251-1Notes on IllnessLN1.2.1.RepeatOf[CLUSTER -- Past Illness].4  0..1STRING
ProceduresCWE73983-9 LN1.347519-4^^LN^416940007 0..1SECTION
Procedure†-   1.3.1.RepeatOf[CLUSTER -- Procedure]  0..*STRUCTURAL
Procedure PerformedCWE29300-1Procedure PerformedLN1.3.1.RepeatOf[CLUSTER -- Procedure].1Constraint (Child of Snomed-CT term 71388002 | Procedure (procedure) |)Y0..1CODEDVALUE
Notes on ProcedureFT8251-1Notes on ProcedureLN1.3.1.RepeatOf[CLUSTER -- Procedure].2  0..1STRING
Family HistoryCWE73983-9 LN1.410157-6^Family History^LN 0..1SECTION
Patients Family Tree IDST74027-4Patients Family Tree IDLN1.4.1  0..1STRING
Natural Father IDST74026-6Natural Father IDLN1.4.2  0..1STRING
Natural Mother IDST74025-8Natural Mother IDLN1.4.3  0..1STRING
RelativesCWE73983-9 LN1.4.4224086007^Relatives^SCT 0..1SECTION
Relative†-   1.4.4.1.RepeatOf[CLUSTER -- Relative]  0..*STRUCTURAL
Relative NameST54138-3Relative NameLN1.4.4.1.RepeatOf[CLUSTER -- Relative].1  0..1STRING
RelationshipCWE44767-2RelationshipLN1.4.4.1.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 IDLN1.4.4.1.RepeatOf[CLUSTER -- Relative].3  0..1STRING
Natural Father IDST74026-6Natural Father IDLN1.4.4.1.RepeatOf[CLUSTER -- Relative].4  0..1STRING
Natural Mother IDST74025-8Natural Mother IDLN1.4.4.1.RepeatOf[CLUSTER -- Relative].5  0..1STRING
deceasedEstimatedAgeST39016-1deceasedEstimatedAgeLN1.4.4.1.RepeatOf[CLUSTER -- Relative].6  0..1REAL
LivingEstimatedAgeST LivingEstimatedAgeLN1.4.4.1.RepeatOf[CLUSTER -- Relative].7  0..1REAL
Clinical Genomic ChoiceCWE74042-3Clinical Genomic ChoiceLN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice]  0..*COLLECTION
Clinical ObservationCWE74023-3Clinical ObservationLN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].1  1..1CODEDVALUE
Negation IndicatorCWE74022-5Negation IndicatorLN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].2  0..1BOOLEAN
Cause of DeathCWE74044-9Cause of DeathLN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].3  0..1BOOLEAN
DataEstimatedAgeST21611-9DataEstimatedAgeLN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].4  0..1REAL
Genetic LociST48018-6Genetic LociLN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].5.RepeatOf[ELEMENT -- Genetic Loci]  0..*STRING
Genetic RisksCWE73983-9 LN1.4.5106221001^Genetic Risks^SCT 0..1SECTION
Pedigree Analysis Results †-   1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results]  0..*STRUCTURAL
Genetic Disease AssessedCWE51967-8Genetic Disease AssessedLN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].1  0..1CODEDVALUE
Input ParametersCWE73983-9 LN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].273983-9^Input Parameters^LN 0..1SECTION
Genetic Algorithm UsedCWE74021-7Genetic Algorithm UsedLN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.1  0..1CODEDVALUE
SensitivityNM74020-9SensitivityLN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.2  0..1PHYSICALQUANTITY
Probability of DiseaseST74019-1Probability of DiseaseLN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].3.RepeatOf[ELEMENT -- Probability of Disease]  0..*REAL
Pregnancy HistoryCWE73983-9 LN1.511449-6^Pregnancy History^LN 0..1SECTION
GravidaNM11996-6GravidaLN1.5.1  0..1INTEGER
ParityNM11977-6ParityLN1.5.2  0..1INTEGER
MiscarriagesNM11614-5MiscarriagesLN1.5.3  0..1INTEGER
TerminationsNM11613-7TerminationsLN1.5.4  0..1INTEGER
Social HistoryCWE73983-9 LN1.629762-2^Social History^LN 0..1SECTION
Social SituationFT10166-7Social SituationLN1.6.1  0..1STRING
Substance UseCWE73983-9 LN1.718663-5^Substance Use^LN 0..1SECTION
Smoking HistoryCWE73983-9 LN1.7.111367-0^Smoking History^LN 0..1SECTION
Tobacco use and exposureCWE63638-1Tobacco use and exposureLN1.7.1.1

Value Set (

8517006^Ex-smoker^SCT

 43381005^Passive smoker^SCT

77176002^Smoker^SCT

8392000^Non-smoker^SCT

)

 0..1CODEDVALUE
Tobacco smoking consumptionNM63858-5Tobacco smoking consumptionLN1.7.1.2  0..1PHYSICALQUANTITY
Lifetime IntakeNM74011-8Lifetime IntakeLN1.7.1.3  0..1PHYSICALQUANTITY
Date CeasedDT74010-0Date CeasedLN1.7.1.4  0..1DATETIME
Alcohol IntakeCWE73983-9 LN1.7.211330-8^Alcohol Intake^LN 0..1SECTION
Alcohol IntakeCWE11331-6Alcohol IntakeLN1.7.2.1

Value Set (

82581004^Ex-drinker^SCT

105542008^Non - drinker^SCT

219006^Current drinker^SCT

)

 0..1CODEDVALUE
Last Drank AlcoholDT74014-2Last Drank AlcoholLN1.7.2.2  0..1DATETIME
30 day quantity and frequencyCWE73983-9 LN1.7.2.373983-9^30 day quantity and frequency^LN 0..1SECTION
Number of days alcohol consumedNM63597-9Number of days alcohol consumedLN1.7.2.3.1  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 daysLN1.7.2.3.2  0..1INTEGER
Average Daily Alcohol IntakeNM74013-4Average Daily Alcohol IntakeLN1.7.2.4  0..1PHYSICALQUANTITY
Maximum Daily Standard DrinksNM63591-2Maximum Daily Standard DrinksLN1.7.2.5  0..1PHYSICALQUANTITY
Years Alcohol ConsumedNM74012-6Years Alcohol ConsumedLN1.7.2.6  0..1PHYSICALQUANTITY
Alcohol abuse or dependence (eg DSM IV)CWE74043-1Alcohol abuse or dependence (eg DSM IV)LN1.7.2.7  0..1BOOLEAN
Other substance UseCWE73983-9 LN1.7.311342-3^Other substance Use^LN 0..1SECTION
Drug misuse detailsCWE228366006Drug misuse detailsSCT1.7.3.1.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 HistoryCWE73983-9 LN1.8266930008^Exercise History^SCT 0..1SECTION
Currently ExercisingCWE74008-4Currently ExercisingLN1.8.1

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..1CODEDVALUE
Exercise TypeCWE73986-2Exercise TypeLN1.8.2

Value Set (

229072005^Aerobic^SCT

)

 0..1CODEDVALUE
Time Spent ExercisingNM74009-2Time Spent ExercisingLN1.8.3  0..1PHYSICALQUANTITY
VitalsCWE73983-9 LN1.98716-3^Vitals^LN 0..1SECTION
Blood PressureCWE73983-9 LN1.9.1.RepeatOf[CLUSTER -- Blood Pressure]55417-0^Blood Pressure^LN 0..*COLLECTION
Systolic PressureNM8480-6Systolic PressureLN1.9.1.RepeatOf[CLUSTER -- Blood Pressure].1 Y0..1PHYSICALQUANTITY
Diastolic PressureNM8462-4Diastolic PressureLN1.9.1.RepeatOf[CLUSTER -- Blood Pressure].2  0..1PHYSICALQUANTITY
Patient PositionCWE8361-8Patient PositionLN1.9.1.RepeatOf[CLUSTER -- Blood Pressure].3

Value Set (

33586001^Sitting^SCT

102538003^Lying^SCT

272580008^Semi-recumbent^SCT

10904000^Standing^SCT

)

 0..1CODEDVALUE
Pulse rateNM8893-0Pulse rateLN1.9.2.RepeatOf[ELEMENT -- Pulse rate] Y0..*PHYSICALQUANTITY
WeightNM29463-7WeightLN1.9.3.RepeatOf[ELEMENT -- Weight] Y0..*PHYSICALQUANTITY
BMINM39156-5BMILN1.9.4.RepeatOf[ELEMENT -- BMI] Y0..*PHYSICALQUANTITY
Oxygen SaturationNM59408-5Oxygen SaturationLN1.9.5.RepeatOf[ELEMENT -- Oxygen Saturation] Y0..*PHYSICALQUANTITY
HeightNM8302-2HeightLN1.9.6.RepeatOf[ELEMENT -- Height] Y0..*PHYSICALQUANTITY
TemperatureNM8310-5TemperatureLN1.9.7.RepeatOf[ELEMENT -- Temperature] Y0..*PHYSICALQUANTITY
Respiratory rateNM9279-1Respiratory rateLN1.9.8.RepeatOf[ELEMENT -- Respiratory rate]  0..*PHYSICALQUANTITY
AlertsCWE73983-9 LN1.1044944-7^Alerts^LN 0..1SECTION
Alert -   1.10.1.RepeatOf[CLUSTER -- Alert]  0..*STRUCTURAL
Alert TypeCWE74018-3Alert TypeLN1.10.1.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..1CODEDVALUE
ActiveCWE74017-5ActiveLN1.10.1.RepeatOf[CLUSTER -- Alert].2  0..1BOOLEAN
Specific AlertCWE44944-7Specific AlertLN1.10.1.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 byLN1.10.1.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..1CODEDVALUE
Recorded dateDT Recorded date 1.10.1.RepeatOf[CLUSTER -- Alert].5  0..1DATETIME

...