Design > Patient Summary Description

Release Information

Project: EGADSS
Internal Release Number: $Revision: 1.1 $
Related Documents: Design > Document Taxonomy

Patient Summary 




 

Element Description Cardinality Data Type Data Type Description

(see HL7 data types

and EGADSS data types for reference)
Vocabulary
Document Information                 
id Unique document identifier; generated by the sending application 1...1 EGADSS_Document_II Instance identifier derived from HL7 "II" data type. 111
code  Type of document; should be drawn from LOINC 1…1 EGADSS_Document_CE "Coded with Equivalents"; used when alternative codes may exist; derived from HL7 "CE" data type. 222                                            EGADSS_01 for “Patient Summary” EGADSS_02 for “Recommendations”
effectiveTime Document creation time 1…1 TS Point in time that signifies when the document came into being  
author Device (software) that created the document 1…* EGADSS.Author This complex data type holds a code for a particular electronic medical record (EMR) system. 333
Demographics            
birthTime Patient’s DOB 0…1 TS Point in time  
administrativeGenderCode Patient's gender 0…1 EGADSS_Gender_CE "Coded with Equivalents"; used when alternative codes may exist; derived from HL7 "CE" data type. HL7: Administrative Gender 2.16.840.1.113883.5.1
maritalStatusCode Patient's marital status 0…1 EGADSS_MaritalStatus_CE "Coded with Equivalents"; used when alternative codes may exist; derived from HL7 "CE" data type. HL7: Marital Status 2.16.840.1.113883.5.2
Active ProblemsLOINC: 11450-4   Section code          
code Medical condition 1…1 EGADSS_Condition_CD "Concept Descriptor" for medical conditions; derived from HL7 data type "CD". ICD-9: 2.16.840.1.113883.6.2
effectiveTime   0…1 IVL_TS Specifies time in intervals  
Past Medical HistoryLOINC: 11348-0effectiveTime            
code Medical condition 1…1 EGADSS_Condition_CD "Concept Descriptor" for medical conditions; derived from HL7 data type "CD". ICD-9-CM: 2.16.840.1.113883.6.2
  0…1 IVL_TS Specifies time in intervals  
Surgical History       LOINC: 10167-5            
code Surgical procedure code 1…1 EGADSS_Surgical_CD "Concept Descriptor" for surgical procedures; derived from HL7 data type "CD". ICD-9-CM: 2.16.840.1.113883.6.2
effectiveTime   0…1 IVL_TS Specifies time in intervals.  
Medications       LOINC: 19789-7            
code Drug Identification Number for the prescribed medication. 1…1 EGADSS_LabeledDrug_CE "Coded with Equivalents" data type for representing medication codes; derived from HL7 data type "CE". Health Canada Drug Product Database
PrescriptionAct. effectiveTime Date when medication was prescribed. 0…* IVL_TS Specifies time in intervals.  
SubstanceAdministration.effectiveTime   0…1 PIVL_TS "Periodic interval of time"; describes the frequency of substance administration.  
doseQuantity Dosage of the prescribed medication (i.e. 2 250mg tablets). 0…1 IVL_PQ "Interval of Physical Quantities" specifies a set of consecutive values of physical quantities.  
routeCode The route the prescribed medication is administered (i.e. oral, nasal, needle). 0…1 EGADSS_SubstanceAdministrationRoute_CE "Coded with Equivalents" data type for representing medication administration route codes; derived from HL7 data type "CE". HL7: MedAdministrationRoute   2.16.840.1.113883.5.112 
Allergies And Adverse Reactions          LOINC: 10123-x                          
code Allergy code 1…1 EGADSS_AllergiesAndAdverseReactions_CD "Concept Descriptor" for allergies; derived from HL7 data type "CD". ICD-9-CM: 2.16.840.1.113883.6.2
Family History   LOINC: 10157-6       
code Medical condition 1…1 EGADSS_Condition_CD "Concept Descriptor" for medical conditions; derived from HL7 data type "CD". ICD-9-CM: 2.16.840.1.113883.6.2
Immunizations    LOINC: 11369-6            
code Immunization code 1…1 EGADSS_Immunization_CD "Concept Descriptor" for immunizations; derived from HL7 data type "CD". BCCDC: BC Vaccination Codes 
effectiveTime   0…1 IVL_TS Specifies time in intervals.  
Social History      LOINC: 29762-2             
code Social factor code 1…1 EGADSS_SocialHistory_CD "Concept Descriptor" for social factor; derived from HL7 data type "CD". ICPC-2                                                    ICD-9-CM: 2.16.840.1.113883.6.2
effectiveTime   0…1 IVL_TS Specifies time in intervals.  
Labs                   LOINC: 11502-2            
code Lab code 1…1 EGADSS_Labs_CD "Concept Descriptor" for labs; derived from HL7 data type "CD". LOINC 2.16.840.1.113883.6.1
value   0…1 ANY .  
effectiveTime   0…1 IVL_TS Specifies time in intervals.  




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