Appendix 9 HL7v2 Virtual Medical Record (Normative)

_{Report template ID}

_RP

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}

_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}

_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}

_{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 the temporal context is unspecified, 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}

_0..1

_SECTION

_Procedure ^†

_-

_{71388002^Procedure^SCT}

_{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}

_0..1

_SECTION

_{Patients Family Tree ID}

_ST

_{74027-4^Patients Family Tree ID^LN}

_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}

_{See Table HL7 v3 FamilyMember Value set below}

_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^Deceased Estimated Age^LN}

_{1.4.4.1.RepeatOf[CLUSTER -- Relative].6}

_0..1

_REAL

_{LivingEstimatedAge}

_ST

_{21612-7^Living Estimated Age^LN}

_{1.4.4.1.RepeatOf[CLUSTER -- Relative].7}

_0..1

_REAL

_{Clinical Genomic Choice}

_CWE

_73983-9^^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}

_{Value Set (}

_{31874001^True^SCT}

_{64100000^False^SCT}

_{64957009^Uncertain^SCT}

₎

_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}

_{Value Set (}

_{31874001^True^SCT}

_{64100000^False^SCT}

_{64957009^Uncertain^SCT}

₎

_0..1

_BOOLEAN

_{DataEstimatedAge}

_ST

_{21611-9^Data Estimated Age^LN}

_{1.4.4.1.RepeatOf[CLUSTER -- Relative].8.RepeatOf[CLUSTER -- Clinical Genomic Choice].4}

_0..1

_REAL