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 Element | OBX-2 DataType | OBX-3 Observation Identifier component | OBX-3 Text component | OBX-3 Name of Coding System component | OBX-3 Alternative Code component | OBX-3 Name of Alternative Coding system | 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 | LN | 1 | HL7V2-VMR.v1^HL7V2 VMR&99A-9AAC5A649D18B6F2&L^TX^Octet-stream | 1 | ENTRY | |||
| History of Presenting Complaint | CWE | 73983-9 | LN | 1.1 | 34046-3^History of Presenting Complaint^LN | 0..1 | SECTION | ||||
| Chief Complaint | CWE | 10154-3 | Chief Complaint | LN | 33962009 | SCT | 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 | LN | 298059007 | SCT | 1.1.2 | 0..1 | DATETIME | ||
| Notes | FT | 8251-1 | Notes | LN | 1.1.3 | 0..1 | STRING | ||||
| History of Past Illness | CWE | 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 | LN | 404684003 | SCT | 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 | 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 this field is unvalued, then 410511007^Current or past^SCT is the assumed value. | 0..1 | CODEDVALUE | |||
| Illness Dates | DR | 11368-8 | Illness Dates | LN | 1.2.1.RepeatOf[CLUSTER -- Past Illness].3 | 0..1 | DATERANGE | ||||
| Notes on Illness | FT | 8251-1 | Notes on Illness | LN | 1.2.1.RepeatOf[CLUSTER -- Past Illness].4 | 0..1 | STRING | ||||
| Procedures | CWE | 73983-9 | LN | 1.3 | 47519-4^^LN^416940007^Procedures^SCT | 0..1 | SECTION | ||||
| Procedure† | - | 1.3.1.RepeatOf[CLUSTER -- Procedure] | 0..* | STRUCTURAL | |||||||
| Procedure Performed | CWE | 29300-1 | 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 | LN | 1.3.1.RepeatOf[CLUSTER -- Procedure].2 | 0..1 | STRING | ||||
| Family History | CWE | 73983-9 | LN | 1.4 | 10157-6^Family History^LN^57177007^Family History^SCT | 0..1 | SECTION | ||||
| Patients Family Tree ID | ST | 74027-4 | Patients Family Tree ID | LN | 422549004 | SCT | 1.4.1 | 0..1 | STRING | ||
| Natural Father ID | ST | 74026-6 | Natural Father ID | LN | 1.4.2 | 0..1 | STRING | ||||
| Natural Mother ID | ST | 74025-8 | Natural Mother ID | LN | 1.4.3 | 0..1 | STRING | ||||
| Relatives | CWE | 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 | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].1 | 0..1 | STRING | ||||
| Relationship | CWE | 44767-2 | 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 | 0..1 | CODEDVALUE | |||
| Relative ID | ST | 74024-1 | Relative ID | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].3 | 0..1 | STRING | ||||
| Natural Father ID | ST | 74026-6 | Natural Father ID | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].4 | 0..1 | STRING | ||||
| Natural Mother ID | ST | 74025-8 | Natural Mother ID | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].5 | 0..1 | STRING | ||||
| deceasedEstimatedAge | ST | 39016-1 | deceasedEstimatedAge | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].6 | 0..1 | REAL | ||||
| LivingEstimatedAge | ST | LivingEstimatedAge | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].7 | 0..1 | REAL | |||||
| Clinical Genomic Choice | CWE | 74042-3 | Clinical Genomic Choice | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice] | 0..* | COLLECTION | ||||
| Clinical Observation | CWE | 74023-3 | 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 | 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 | LN | 1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].3 | 0..1 | BOOLEAN | ||||
| DataEstimatedAge | ST | 21611-9 | DataEstimatedAge | 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 | 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 | LN | 1.4.5 | 106221001^Genetic Risks^SCT | 0..1 | SECTION | ||||
| Pedigree Analysis Results † | - | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results] | 0..* | STRUCTURAL | |||||||
| Genetic Disease Assessed | CWE | 51967-8 | Genetic Disease Assessed | LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].1 | 0..1 | CODEDVALUE | ||||
| Input Parameters | CWE | 73983-9 | LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2 | ^Input Parameters | 0..1 | SECTION | ||||
| Genetic Algorithm Used | CWE | 74021-7 | Genetic Algorithm Used | LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.1 | 0..1 | CODEDVALUE | ||||
| Sensitivity | NM | 74020-9 | 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 | LN | 1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].3.RepeatOf[ELEMENT -- Probability of Disease] | 0..* | REAL | ||||
| Pregnancy History | CWE | 73983-9 | LN | 1.5 | 118185001^Pregnancy History^SCT | 0..1 | SECTION | ||||
| Gravida | NM | 11996-6 | Gravida | LN | 161732006 | SCT | 1.5.1 | 0..1 | INTEGER | ||
| Parity | NM | 11977-6 | Parity | LN | 364325004 | SCT | 1.5.2 | 0..1 | INTEGER | ||
| Miscarriages | NM | 11614-5 | Miscarriages | LN | 248989003 | SCT | 1.5.3 | 0..1 | INTEGER | ||
| Terminations | NM | 11613-7 | Terminations | LN | 252114001 | SCT | 1.5.4 | 0..1 | INTEGER | ||
| Social History | CWE | 73983-9 | LN | 1.6 | 29762-2^Social History^LN^160476009^^SCT | 0..1 | SECTION | ||||
| Social Situation | FT | 10166-7 | Social Situation | LN | 1.6.1 | 0..1 | STRING | ||||
| Substance Use | CWE | 73983-9 | LN | 1.7 | 409069009^Substance Use^SCT | 0..1 | SECTION | ||||
| Smoking History | CWE | 73983-9 | LN | 1.7.1 | 365981007^Smoking History^SCT | 0..1 | SECTION | ||||
| Tobacco use and exposure | CWE | 63638-1 | Tobacco use and exposure | LN | 229819007 | SCT | 1.7.1.1 | 0..1 | CODEDVALUE | ||
| Tobacco smoking consumption | NM | 63858-5 | Tobacco smoking consumption | LN | 266918002 | SCT | 1.7.1.2 | 0..1 | PHYSICALQUANTITY | ||
| Lifetime Intake | NM | 74011-8 | Lifetime Intake | LN | 401201003 | SCT | 1.7.1.3 | 0..1 | PHYSICALQUANTITY | ||
| Date Ceased | DT | 74010-0 | Date Ceased | LN | 1.7.1.4 | 0..1 | DATETIME | ||||
| Alcohol Intake | CWE | 73983-9 | LN | 1.7.2 | 228273003^Alcohol Intake^SCT | 0..1 | SECTION | ||||
| Alcohol Intake | CWE | 11331-6 | Alcohol Intake | LN | 160573003 | SCT | 1.7.2.1 | 0..1 | CODEDVALUE | ||
| Last Drank Alcohol | DT | 74014-2 | Last Drank Alcohol | LN | 1.7.2.2 | 0..1 | DATETIME | ||||
| 30 day quantity and frequency | CWE | 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 | 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 | LN | 1.7.2.3.2 | 0..1 | INTEGER | ||||
| Average Daily Alcohol Intake | NM | 74013-4 | Average Daily Alcohol Intake | LN | 443315005 | SCT | 1.7.2.4 | 0..1 | PHYSICALQUANTITY | ||
| Maximum Daily Standard Drinks | NM | 63591-2 | Maximum Daily Standard Drinks | LN | 442547005 | SCT | 1.7.2.5 | 0..1 | PHYSICALQUANTITY | ||
| Years Alcohol Consumed | NM | 74012-6 | Years Alcohol Consumed | LN | 228330005 | SCT | 1.7.2.6 | 0..1 | PHYSICALQUANTITY | ||
| Alcohol abuse or dependence (eg DSM IV) | CWE | 74043-1 | Alcohol abuse or dependence (eg DSM IV) | LN | 15167005 | SCT | 1.7.2.7 | 0..1 | BOOLEAN | ||
| Other substance Use | CWE | 73983-9 | LN | 1.7.3 | 363908000^Other substance Use^SCT | 0..1 | SECTION | ||||
| Drug misuse details | CWE | 228366006 | Drug misuse details | SCT | 1.7.3.1.RepeatOf[ELEMENT -- Drug misuse details] | 0..* | CODEDVALUE | ||||
| Exercise History | CWE | 73983-9 | LN | 1.8 | 74008-4^Exercise History^LN^266930008^Exercise History^SCT | 0..1 | SECTION | ||||
| Currently Exercising | CWE | Currently Exercising | LN | 1.8.1 | 0..1 | CODEDVALUE | |||||
| Exercise Type | CWE | 73986-2 | Exercise Type | LN | 1.8.2 | 0..1 | CODEDVALUE | ||||
| Time Spent Exercising | NM | 74009-2 | Time Spent Exercising | LN | 1.8.3 | 0..1 | PHYSICALQUANTITY | ||||
| Vitals | CWE | 73983-9 | LN | 1.9 | 46680005^Vitals^SCT | 0..1 | SECTION | ||||
| Blood Pressure | CWE | 73983-9 | LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure] | 55417-0^Blood Pressure^LN^75367002^Blood Pressure^SCT | 0..* | COLLECTION | ||||
| Systolic Pressure | NM | 8480-6 | Systolic Pressure | LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure].1 | Y | 0..1 | PHYSICALQUANTITY | |||
| Diastolic Pressure | NM | 8462-4 | Diastolic Pressure | LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure].2 | 0..1 | PHYSICALQUANTITY | ||||
| Patient Position | CWE | 8361-8 | Patient Position | LN | 1.9.1.RepeatOf[CLUSTER -- Blood Pressure].3 | 0..1 | CODEDVALUE | ||||
| Pulse rate | NM | 8893-0 | Pulse rate | LN | 1.9.2.RepeatOf[ELEMENT -- Pulse rate] | Y | 0..* | PHYSICALQUANTITY | |||
| Weight | NM | 29463-7 | Weight | LN | 1.9.3.RepeatOf[ELEMENT -- Weight] | Y | 0..* | PHYSICALQUANTITY | |||
| BMI | NM | 39156-5 | BMI | LN | 1.9.4.RepeatOf[ELEMENT -- BMI] | Y | 0..* | PHYSICALQUANTITY | |||
| Oxygen Saturation | NM | 59408-5 | Oxygen Saturation | LN | 1.9.5.RepeatOf[ELEMENT -- Oxygen Saturation] | Y | 0..* | PHYSICALQUANTITY | |||
| Height | NM | 8302-2 | Height | LN | 1.9.6.RepeatOf[ELEMENT -- Height] | Y | 0..* | PHYSICALQUANTITY | |||
| Temperature | NM | 8310-5 | Temperature | LN | 1.9.7.RepeatOf[ELEMENT -- Temperature] | Y | 0..* | PHYSICALQUANTITY | |||
| Respiratory rate | NM | 9279-1 | Respiratory rate | LN | 1.9.8.RepeatOf[ELEMENT -- Respiratory rate] | 0..* | PHYSICALQUANTITY | ||||
| Alerts | CWE | 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 | LN | 1.10.1.RepeatOf[CLUSTER -- Alert].1 | 0..1 | CODEDVALUE | ||||
| Active | CWE | 74017-5 | Active | LN | 1.10.1.RepeatOf[CLUSTER -- Alert].2 | 0..1 | BOOLEAN | ||||
| Specific Alert | CWE | 44944-7 | Specific Alert | LN | 1.10.1.RepeatOf[CLUSTER -- Alert].3 | 0..1 | CODEDVALUE | ||||
| Reported by | CWE | 74015-9 | Reported by | LN | 1.10.1.RepeatOf[CLUSTER -- Alert].4 | 0..1 | CODEDVALUE | ||||
| Recorded date | DT | Recorded date | 1.10.1.RepeatOf[CLUSTER -- Alert].5 | 0..1 | DATETIME |
...
OBX-2, OBX-3 values must be as listed in the table.
OBX-5 value domains are suggested and recommended. Systems However, systems should use the values that they have available in their systems.
...