| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
Composition
|
ClinicalDocument | MedNet Interface (MNI) - PatientOverview Composition | ||
id
|
S | The id is unique within the space of all resources of the same type on the same server It can be any combination of upper- or lower-case ASCII letters 'A'..'Z', and 'a'..'z', numerals ('0'..'9'), '-' and '.' with a length limit of 64 characters. (This might be an integer, an un-prefixed OID, UUID or any other identifier pattern that meets these constraints.) | ||
|
status
|
S |
This version of the composition is complete and verified by an appropriate person and no further work is planned. Any subsequent updates would be on a new version of the composition. Fixed Value: final |
||
|
type
|
S |
Fixed loinc code 60591-5 = Patient summary Document Required Pattern: At least the following |
||
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 60591-5 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Patient summary Document |
|
subject
|
S | 1.. | Reference (MedNet Interface (MNI) - Patient) | Link to the Patient |
|
encounter
|
S | Reference (MedNet Interface (MNI) - Encounter) | An encounter will provide information about the context in which the form will be filled It is mainly used to deliver MedNet the Visit Nr (or Case Nr), and/or the orderNr from the calling System. The goal of those values is to allow saving the copy of the form and/or the later resulting report in the calling system to an internal event. It can also include informations about the priority of the request (if it is urgent or not), or the type of form that should be filled. | |
|
date
|
S | |||
|
author
|
S | Reference (MedNet Interface (MNI) - Device | MedNet Interface (MNI) - SoftwareUser) | ||
|
title
|
S | Fixed Value: PatientOverview | ||
|
confidentiality
|
S | 1.. |
N = normal Fixed Value: N |
|
Slices for section
|
S | Slice: Unordered, Open by pattern:$this.code | ||
section:insuranceData
|
S | 0..1 | This section will provide patient insurance information | |
title
|
S | 1..1 | Fixed Value: Insurance data section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 76437-3 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Primary insurance |
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
entry:Coverage
|
S | 1..* | Reference (MedNet Interface (MNI) - Coverage) { b } |
The coverage objects that will include all the informations about the insurances and invoices management |
|
section:sectionMedications
|
S | 0..1 | This section will provide all the Medication taken by the patient | |
|
title
|
S | 1..1 | Fixed Value: Medication Summary section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 10160-0 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: History of Medication use Narrative |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:medicationStatement
|
S | 1..* | Reference (MedNet Interface (MNI) - Medication Statement) { b } |
A record of a medication that is being consumed by a patient |
|
section:sectionAllergies
|
S | 0..1 | This section will provide detailed information about allergies or intolerances of the patient (generally: Risk of adverse reaction to a substance) | |
|
title
|
S | 1..1 | Fixed Value: Allergies section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 48765-2 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Allergies and adverse reactions Document |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:allergyOrIntolerance
|
S | 1..* | Reference (MedNet Interface (MNI) - Allergy Intolerance) { b } |
An allergy or intolerance record |
|
section:sectionProblems
|
S | 0..1 | This section will provide detailed information about conditions, problems or diagnoses (German = Diagnose, French = Diagnostics) | |
|
title
|
S | 1..1 | Fixed Value: Problems section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 11450-4 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Problem list - Reported |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:problem
|
S | 1..* | Reference (MedNet Interface (MNI) - Condition) { b } |
A problem record |
|
section:sectionProceduresHx
|
S | 0..1 | This section will provide detailed information about actions that are or were performed on or for a patient. This can be physical interventions like an operations, or less invasive like long term services, counseling, or hypnotherapy. (German = Massnahme, French = Intervention) | |
|
title
|
S | 1..1 | Fixed Value: Procedures section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 47519-4 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: History of Procedures Document |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:procedure
|
S | 1..* | Reference (MedNet Interface (MNI) - Procedure) { b } |
A procedure record |
|
section:sectionResults
|
S | 0..1 | This section will provide some relevant laboratory observations | |
|
title
|
S | 1..1 | Fixed Value: Results section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 30954-2 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Relevant diagnostic tests/laboratory data Narrative |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:results-observation
|
S | 1..* | Reference (MedNet Interface (MNI) - Laboratory Observation) { b } |
Laboratory Observation |
|
section:sectionVitalSigns
|
S | 0..1 | This section will provide detailed information about patient vital signs | |
|
title
|
S | 1..1 | Fixed Value: Vital signs section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 8716-3 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Vital signs |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:bodyWeight
|
S | 0..1 | Reference (MedNet Interface (MNI) - Body Weight) { b } | Body Weight of the patient |
|
entry:bodyHeight
|
S | 0..1 | Reference (MedNet Interface (MNI) - Body Height) { b } | Bodyheight of the patient |
|
entry:bodyMassIndex
|
S | 0..1 | Reference (MedNet Interface (MNI) - Body Mass Index) { b } | Body Mass Index of the patient |
|
entry:bloodPressure
|
S | 0..1 | Reference (MedNet Interface (MNI) - Blood Pressure) { b } | Blood pressure of the patient |
|
entry:bloodGroup
|
S | 0..1 | Reference (MedNet Interface (MNI) - Blood Group) { b } | Blood group of the patient |
|
entry:dateOfLastMenstruation
|
S | 0..1 | Reference (MedNet Interface (MNI) - First day of last menstruation) { b } | Date of last menstruation (German = Ersten Tag der letzte Monatsblutung, French = Premier jour des dernières règles) |
|
section:sectionSocialHistory
|
S | 0..1 | This section will provide detailed information potential outcomes and family members cases | |
|
title
|
S | 1..1 | Fixed Value: Social history section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 29762-2 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Social history Narrative |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:riskFactors
|
S | 0..* | Reference (MedNet Interface (MNI) - Risk Factor) { b } |
Potential outcomes for a subject with likelihood (CAVE). (German = Risiko Factor , French = Facteur de risque ) |
|
entry:familyMemberHistory
|
S | 0..* | Reference (MedNet Interface (MNI) - Family Member History) { b } |
Information about patient's relatives, relevant for patient. (German = Familienanamnese, French = Anamnèse familiale |
|
section:sectionPregnancyHx
|
S | 0..1 | This section will provide medical informations dedicated to pregnancy. This section must be delivered only if the patient is Pregnant. | |
|
title
|
S | 1..1 | Fixed Value: Pregnancy section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 10162-6 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: History of pregnancies Narrative |
|
|
Slices for entry
|
S | 0 .. * |
A reference to pregnancy information. If no entry is specified, but the section exists, it means that the Patient is pregnant but no additional informations are available
Slice: Unordered, Open by profile:resolve() |
|
|
entry:estimatedDateOfConception
|
S | 0..1 | Reference (MedNet Interface (MNI) - Estimated date of conception) { b } | Estimated date of conception (German = Geschätzte Konzeptions Datum, French = Date de conception estimée) |
|
entry:estimatedDateOfDelivery
|
S | 0..1 | Reference (MedNet Interface (MNI) - Estimated date of delivery) { b } | Estimated date of delivery (German = Geplante Geburts Datum, French = Date d'accouchement prévue) |
|
entry:dateOfLastMenstruation
|
S | 0..1 | Reference (MedNet Interface (MNI) - First day of last menstruation) { b } | Date of last menstruation (German = Ersten Tag der letzte Monatsblutung, French = Premier jour des dernières règles) |
|
entry:timeOfGestation
|
S | 0..1 | Reference (MedNet Interface (MNI) - Time of gestation) { b } | Time of gestation (German = Tage/Woche seit Schwangerschaft Beginn / Schwangerschaftswoche / SSW, French = Nombre de jour/semaine depuis le début de la grossesse) |
|
section:annotations
|
S | 0..1 | This section will provide information that can not be structured in the previous sections but that can be usefull for filling a form. | |
|
title
|
S | 1..1 | Fixed Value: Comment | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 48767-8 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Annotation comment [Interpretation] Narrative |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:observation
|
S | 1..* | Reference (MedNet Interface (MNI) - Annotation Observation) { b } |
An annotation observation record |
|
section:documents
|
S | 0..1 | This section will provide relevant documents | |
|
title
|
S | 1..1 | Fixed Value: Documents section | |
|
code
|
S | 1..1 | Required Pattern: At least the following | |
|
coding
|
1..* | Coding |
Code defined by a terminology system Fixed Value: (complex) |
|
|
system
|
1..1 | uri |
Identity of the terminology system Fixed Value: http://loinc.org |
|
|
code
|
1..1 | code |
Symbol in syntax defined by the system Fixed Value: 51899-3 |
|
|
display
|
1..1 | string |
Representation defined by the system Fixed Value: Details Document |
|
|
Slices for entry
|
S | 1 .. * |
Slice:
Unordered, Open by profile:resolve()
|
|
|
entry:Document
|
S | 1..* | Reference (MedNet Interface (MNI) - DocumentReference) { b } |
Document |
|
Documentation for this format
|
||||