The social history section contains a description of the person’s Health related “lifestyle factors" or "lifestyle observations" (e.g. smoke habits; alcohol consumption; diets, risky habits.) The optional author and informant elements are used when necessary to convey the provenance and authoring of the section content in case it is different from what is announced in the CDA header.
Kontext
Elternknoten des Template-Element mit Id 2.16.840.1.113883.10.22.3.10
Klassifikation
CDA Section level template
Offen/Geschlossen
Offen (auch andere als die definierten Elemente sind erlaubt)
Assoziiert mit
Assoziiert mit 3 Konzepte
Id
Name
Datensatz
hl7ips-dataelement-147
Life Style Factor list
CEN/TC 251 prEN 17269
hl7ips-dataelement-149
Description
CEN/TC 251 prEN 17269
hl7ips-dataelement-20
Social History
CEN/TC 251 prEN 17269
Benutzt
Benutzt 6 Templates
Benutzt
als
Name
Version
2.16.840.1.113883.10.22.4.14
Inklusion
IPS Body Author (STU1)
DYNAMIC
2.16.840.1.113883.10.12.319
Containment
CDA Informant (Body)
DYNAMIC
2.16.840.1.113883.10.22.4.34
Containment
IPS Social History Tobacco Use (STU1)
DYNAMIC
2.16.840.1.113883.10.22.4.35
Containment
IPS Social History Alcohol Use (STU1)
DYNAMIC
2.16.840.1.113883.10.22.4.48
Containment
IPS Social History Observation (TI-2020)
DYNAMIC
2.16.840.1.113883.10.22.3.15
Containment
IPS Translation Section (2021)
DYNAMIC
Beziehung
Version: Template 2.16.840.1.113883.10.22.3.10 IPS Social History Section (2017‑04‑13)
ref
hl7ips-
Adaptation: Template 1.3.6.1.4.1.19376.1.5.3.1.3.16 IHE Social History Section (DYNAMIC)
ref
IHE-PCC-
Adaptation: Template 2.16.840.1.113883.10.20.1.15 Social history section (DYNAMIC)
ref
ccd1-
Adaptation: Template 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (DYNAMIC)
ref
bccdapilot-
Beispiel
Beispiel
<sectionclassCode="DOCSECT"> <templateIdroot="2.16.840.1.113883.10.22.3.10"/><idroot="1.2.3.999"extension="__example only__"/><codecode="29762-2"codeSystem="2.16.840.1.113883.6.1"displayName="Social history Narrative"/><title>Social History</title><text> Social History text </text><author> <!-- template 2.16.840.1.113883.10.22.4.14 'IPS Body Author' (dynamic) --> </author><informant> <!-- template 2.16.840.1.113883.10.12.319 'CDA Informant (Body)' (dynamic) --> </informant><entrytypeCode="COMP"contextConductionInd="true"> <!-- template 2.16.840.1.113883.10.22.4.34 'IPS Social History Tobacco Use' (dynamic) --> </entry><entrytypeCode="COMP"contextConductionInd="true"> <!-- template 2.16.840.1.113883.10.22.4.35 'IPS Social History Alcohol Use' (dynamic) --> </entry><component> <!-- template 2.16.840.1.113883.10.22.3.15 'IPS Translation Section' (dynamic) --> </component></section>
Item
DT
Kard
Konf
Beschreibung
Label
hl7:section
1 … 1
M
hl7ips-dataelement-20
Social History
CEN/TC 251 prEN 17269
@classCode
cs
0 … 1
F
DOCSECT
hl7:templateId
II
1 … 1
M
@root
uid
1 … 1
F
2.16.840.1.113883.10.22.3.10
hl7:id
II
0 … *
R
hl7:code
CE.IPS
1 … 1
M
@code
CONF
1 … 1
F
29762-2
@codeSystem
1 … 1
F
2.16.840.1.113883.6.1 (LOINC)
hl7:title
ST
1 … 1
M
Social History
hl7:text
SD.TEXT
1 … 1
M
hl7ips-dataelement-149
Description
CEN/TC 251 prEN 17269
Eingefügt
0 … *
von 2.16.840.1.113883.10.22.4.14 IPS Body Author (DYNAMIC)
hl7:author
0 … *
hl7:templateId
II
1 … 1
M
@root
uid
1 … 1
F
2.16.840.1.113883.10.22.4.14
hl7:time
TS.IPS.TZ
1 … 1
R
hl7:assignedAuthor
1 … 1
M
hl7:id
II
1 … *
R
hl7:code
0 … 1
R
Auswahl
0 … 1
Elemente in der Auswahl:
hl7:assignedPerson
hl7:assignedAuthoringDevice
hl7:assignedPerson
0 … 1
C
@classCode
cs
0 … 1
F
PSN
@determinerCode
cs
0 … 1
F
INSTANCE
hl7:name
PN
1 … *
R
Name of the person (e.g. the Healthcare Professional) authoring this document