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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).

 

OBX-3 Text componentOBX-2 DataTypeOBX-3 Observation Identifier componentOBX-3 Name of Coding System componentOBX-4 Observation sub-IDOBX-5 Observation valueOBX-14 Date/time of the observationOCCURENCESVMR DATATYPE
Report template IDRP74028-2LN1HL7V2-VMR.v1^HL7V2 VMR&99A-9AAC5A649D18B6F2&L^TX^Octet-stream 1ENTRY
History of Presenting ComplaintCWE73983-9LN1.1^History of Presenting Complaint 0..1SECTION
Chief ComplaintCWE10154-3LN1.1.1Constraint (Child of Snomed-CT term 404684003 | Clinical finding (finding)) 0..1CODEDVALUE
Date of OnsetTS11368-8LN1.1.2  0..1DATETIME
NotesFT8251-1LN1.1.3  0..1STRING
History of Past IllnessCWE73983-9LN1.2^History of Past Illness 0..1SECTION
Past Illness †-  1.2.1.RepeatOf[CLUSTER -- Past Illness]  0..*STRUCTURAL
Past IllnessCWE11349-8LN1.2.1.RepeatOf[CLUSTER -- Past Illness].1  0..1CODEDVALUE
Temporal ContextCWE LN1.2.1.RepeatOf[CLUSTER -- Past Illness].2  0..1CODEDVALUE
Illness DatesDR11368-8LN1.2.1.RepeatOf[CLUSTER -- Past Illness].3  0..1DATERANGE
Notes on IllnessFT8251-1LN1.2.1.RepeatOf[CLUSTER -- Past Illness].4  0..1STRING
ProceduresCWE73983-9LN1.3^Procedures 0..1SECTION
Procedure †-  1.3.1.RepeatOf[CLUSTER -- Procedure]  0..*STRUCTURAL
Procedure PerformedCWE29300-1LN1.3.1.RepeatOf[CLUSTER -- Procedure].1Constraint (Child of Snomed-CT term 71388002 | Procedure (procedure) |)Y0..1CODEDVALUE
Notes on ProcedureFT8251-1LN1.3.1.RepeatOf[CLUSTER -- Procedure].2  0..1STRING
Family HistoryCWE73983-9LN1.4^Family History 0..1SECTION
Patients Family Tree IDST74027-4LN1.4.1  0..1STRING
Natural Father IDST74026-6LN1.4.2  0..1STRING
Natural Mother IDST74025-8LN1.4.3  0..1STRING
RelativesCWE73983-9LN1.4.4^Relatives 0..1SECTION
Relative †-  1.4.4.1.RepeatOf[CLUSTER -- Relative]  0..*STRUCTURAL
Relative NameST54138-3LN1.4.4.1.RepeatOf[CLUSTER -- Relative].1  0..1STRING
RelationshipCWE44767-2LN1.4.4.1.RepeatOf[CLUSTER -- Relative].2

Constraint (HL7 v3 FamilyMember Value set = Role Code _PersonalRelationshipRoleType FAMMEMB)

Use "HL7V3RoleCode" for Name of Coding System component of CWE

 0..1CODEDVALUE
Relative IDST74024-1LN1.4.4.1.RepeatOf[CLUSTER -- Relative].3  0..1STRING
Natural Father IDST74026-6LN1.4.4.1.RepeatOf[CLUSTER -- Relative].4  0..1STRING
Natural Mother IDST74025-8LN1.4.4.1.RepeatOf[CLUSTER -- Relative].5  0..1STRING
deceasedEstimatedAgeST39016-1LN1.4.4.1.RepeatOf[CLUSTER -- Relative].6  0..1REAL
LivingEstimatedAgeST LN1.4.4.1.RepeatOf[CLUSTER -- Relative].7  0..1REAL
Clinical Genomic ChoiceCWE74042-3LN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice]  0..*COLLECTION
Clinical ObservationCWE74023-3LN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].1  1..1CODEDVALUE
Negation IndicatorCWE74022-5LN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].2  0..1BOOLEAN
Cause of DeathCWE74044-9LN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].3  0..1BOOLEAN
DataEstimatedAgeST21611-9LN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].4  0..1REAL
Genetic LociST48018-6LN1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].5.RepeatOf[ELEMENT -- Genetic Loci]  0..*STRING
Genetic RisksCWE73983-9LN1.4.5^Genetic Risks 0..1SECTION
Pedigree Analysis Results †-  1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results]  0..*STRUCTURAL
Genetic Disease AssessedCWE51967-8LN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].1  0..1CODEDVALUE
Input ParametersCWE73983-9LN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2^Input Parameters 0..1SECTION
Genetic Algorithm UsedCWE74021-7LN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.1  0..1CODEDVALUE
SensitivityNM74020-9LN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].2.2  0..1PHYSICALQUANTITY
Probability of DiseaseST74019-1LN1.4.5.1.RepeatOf[CLUSTER -- Pedigree Analysis Results].3.RepeatOf[ELEMENT -- Probability of Disease]  0..*REAL
Pregnancy HistoryCWE73983-9LN1.5^Pregnancy History 0..1SECTION
GravidaNM11996-6LN1.5.1  0..1INTEGER
ParityNM11977-6LN1.5.2  0..1INTEGER
MiscarriagesNM11614-5LN1.5.3  0..1INTEGER
TerminationsNM11613-7LN1.5.4  0..1INTEGER
Social HistoryCWE73983-9LN1.6^Social History 0..1SECTION
Social SituationFT10166-7LN1.6.1  0..1STRING
Substance UseCWE73983-9LN1.7^Substance Use 0..1SECTION
Smoking HistoryCWE73983-9LN1.7.1^Smoking History 0..1SECTION
Tobacco use and exposureCWE63638-1LN1.7.1.1  0..1CODEDVALUE
Tobacco smoking consumptionNM63858-5LN1.7.1.2  0..1PHYSICALQUANTITY
Lifetime IntakeNM74011-8LN1.7.1.3  0..1PHYSICALQUANTITY
Date CeasedDT74010-0LN1.7.1.4  0..1DATETIME
Alcohol IntakeCWE73983-9LN1.7.2^Alcohol Intake 0..1SECTION
Alcohol IntakeCWE11331-6LN1.7.2.1  0..1CODEDVALUE
Last Drank AlcoholDT74014-2LN1.7.2.2  0..1DATETIME
30 day quantity and frequencyCWE73983-9LN1.7.2.3^30 day quantity and frequency 0..1SECTION
Number of days alcohol consumedNM63597-9LN1.7.2.3.1  0..1INTEGER
Standard drinks per day on a drinking day in last 30 daysNM63598-7LN1.7.2.3.2  0..1INTEGER
Average Daily Alcohol IntakeNM74013-4LN1.7.2.4  0..1PHYSICALQUANTITY
Maximum Daily Standard DrinksNM63591-2LN1.7.2.5  0..1PHYSICALQUANTITY
Years Alcohol ConsumedNM74012-6LN1.7.2.6  0..1PHYSICALQUANTITY
Alcohol abuse or dependence (eg DSM IV)CWE74043-1LN1.7.2.7  0..1BOOLEAN
Other substance UseCWE73983-9LN1.7.3^Other substance Use 0..1SECTION
Drug misuse detailsCWE73983-9LN1.7.3.1.RepeatOf[ELEMENT -- Drug misuse details]  0..*CODEDVALUE
Exercise HistoryCWE74008-4LN1.8^Exercise History 0..1SECTION
Currently ExercisingCWE  LN1.8.1  0..1CODEDVALUE
Exercise TypeCWE73986-2LN1.8.2  0..1CODEDVALUE
Time Spent ExercisingNM74009-2LN1.8.3  0..1PHYSICALQUANTITY
VitalsCWE73983-9LN1.9^Vitals 0..1SECTION
Blood PressureCWE55417-0LN1.9.1.RepeatOf[CLUSTER -- Blood Pressure]  0..*COLLECTION
Systolic PressureNM8480-6LN1.9.1.RepeatOf[CLUSTER -- Blood Pressure].1 Y0..1PHYSICALQUANTITY
Diastolic PressureNM8462-4LN1.9.1.RepeatOf[CLUSTER -- Blood Pressure].2  0..1PHYSICALQUANTITY
Patient PositionCWE8361-8LN1.9.1.RepeatOf[CLUSTER -- Blood Pressure].3  0..1CODEDVALUE
Pulse rateNM8893-0LN1.9.2.RepeatOf[ELEMENT -- Pulse rate] Y0..*PHYSICALQUANTITY
WeightNM29463-7LN1.9.3.RepeatOf[ELEMENT -- Weight] Y0..*PHYSICALQUANTITY
BMINM39156-5LN1.9.4.RepeatOf[ELEMENT -- BMI] Y0..*PHYSICALQUANTITY
Oxygen SaturationNM59408-5LN1.9.5.RepeatOf[ELEMENT -- Oxygen Saturation] Y0..*PHYSICALQUANTITY
HeightNM8302-2LN1.9.6.RepeatOf[ELEMENT -- Height] Y0..*PHYSICALQUANTITY
TemperatureNM8310-5LN1.9.7.RepeatOf[ELEMENT -- Temperature] Y0..*PHYSICALQUANTITY
Respiratory rateNM9279-1LN1.9.8.RepeatOf[ELEMENT -- Respiratory rate]  0..*PHYSICALQUANTITY
AlertsCWE73983-9LN1.10^Alerts 0..1SECTION
Alert -  1.10.1.RepeatOf[CLUSTER -- Alert]  0..*STRUCTURAL
Alert TypeCWE74018-3LN1.10.1.RepeatOf[CLUSTER -- Alert].1  0..1CODEDVALUE
ActiveCWE74017-5LN1.10.1.RepeatOf[CLUSTER -- Alert].2  0..1BOOLEAN
Specific AlertCWE44944-7LN1.10.1.RepeatOf[CLUSTER -- Alert].3  0..1CODEDVALUE
Reported byCWE74015-9LN1.10.1.RepeatOf[CLUSTER -- Alert].4  0..1CODEDVALUE
Recorded dateDT  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

 

 

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