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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

This appendix make use of aspects from "HL7 Version 2 Implementation Guide: Implementing the Virtual Medical Record for Clinical Decision Support (vMR-CDS), Release 1 " (you may need an account with HL7 International to download).

 

Section Heading or ElementOBX-2 DataTypeOBX-3 Observation Identifier componentOBX-3 Text componentOBX-3 Name of Coding System componentOBX-3 Alternative Code componentOBX-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^Procedures^SCT 0..1SECTION
Procedure †-     1.3.1.RepeatOf[CLUSTER -- Procedure]  0..*STRUCTURAL
Procedure PerformedCWE29300-1Procedure PerformedLN  1.3.1.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^57177007^Family History^SCT 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

 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 †-     1.4.5.1.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 Parameters 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^SCT 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^^SCT 0..1SECTION
Social SituationFT10166-7Social SituationLN  1.6.1  0..1STRING
Substance UseCWE73983-9 LN  1.7409069009^Substance Use^SCT 0..1SECTION
Smoking HistoryCWE73983-9 LN  1.7.1365981007^Smoking History^SCT 0..1SECTION
Tobacco use and exposureCWE63638-1Tobacco use and exposureLN229819007SCT1.7.1.1  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^SCT 0..1SECTION
Alcohol IntakeCWE11331-6Alcohol IntakeLN160573003SCT1.7.2.1  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 day quantity and frequency^PHENX 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  1.7.2.3.2  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 substance Use^SCT 0..1SECTION
Drug misuse detailsCWE228366006Drug misuse detailsSCT  1.7.3.1.RepeatOf[ELEMENT -- Drug misuse details]  0..*CODEDVALUE
Exercise HistoryCWE73983-9 LN  1.874008-4^Exercise History^LN^266930008^Exercise History^SCT 0..1SECTION
Currently ExercisingCWE  Currently ExercisingLN  1.8.1  0..1CODEDVALUE
Exercise TypeCWE73986-2Exercise TypeLN  1.8.2  0..1CODEDVALUE
Time Spent ExercisingNM74009-2Time Spent ExercisingLN  1.8.3  0..1PHYSICALQUANTITY
VitalsCWE73983-9 LN  1.946680005^Vitals^SCT 0..1SECTION
Blood PressureCWE73983-9 LN  1.9.1.RepeatOf[CLUSTER -- Blood Pressure]55417-0^Blood Pressure^LN^75367002^Blood Pressure^SCT 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  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  0..1CODEDVALUE
ActiveCWE74017-5ActiveLN  1.10.1.RepeatOf[CLUSTER -- Alert].2  0..1BOOLEAN
Specific AlertCWE44944-7Specific AlertLN  1.10.1.RepeatOf[CLUSTER -- Alert].3  0..1CODEDVALUE
Reported byCWE74015-9Reported byLN  1.10.1.RepeatOf[CLUSTER -- Alert].4  0..1CODEDVALUE
Recorded dateDT Recorded date   1.10.1.RepeatOf[CLUSTER -- Alert].5  0..1DATETIME

 

Nodes marked VMR STRUCTURAL should not be written to OBX segments and are present in the table to assist with understanding the hierarchy.

The Report Template OBX must be specified and its OBX-4 column SubID must be a dotted decimal value, for this profile "1" has been specified as the root sub ID. All other HL7.VMR OBX subID should have dotted sub id based on this.

 

The first OBX is static and should be as follows:

OBX|1|RP|74028-2^Report template ID^LN|1|HL7V2-VMR.v1^HL7V2 VMR&99A-9AAC5A649D18B6F2&L^TX^Octet-stream||||||F

 

 

OBX|2|CWE|73983-9^^LN^CLUSTER^^EN 13606|1.1|^History of Presenting Complaint||||||F

 

OBX-2, OBX-3 values must be as listed in the table.

OBX-5 value domains are suggested and recommended. However, systems should use the values that they have available in their systems.

 

 

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