Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Example Binary: Vital Signs Section Example

This content is an example of the Vital Signs Section Logical Model and is not a FHIR Resource

    
<section xmlns="urn:hl7-org:v3" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
  <templateId root="2.16.840.1.113883.10.20.22.2.4.1" extension="2015-08-01" />
  <code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Vital signs" />
  <title>Vital Signs (Last Filed)</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Date</th>
          <th>Blood Pressure</th>
          <th>Average Blood Pressure</th>
          <th>Pulse</th>
          <th>Temperature</th>
          <th>Respiratory Rate</th>
          <th>Height</th>
          <th>Weight</th>
          <th>BMI</th>
          <th>SpO2</th>
        </tr>
      </thead>
      <tbody>
        <tr>
          <td>05/20/2014 7:36pm</td>
          <!-- You can consolidate Systolic and Diastolic in human view if desired but should retain separate references-->
          <td>
            <content ID="SystolicBP_1">120</content>/<content ID="DiastolicBP_1">80</content>mm[Hg] </td>
          <!-- You can consolidate Systolic and Diastolic in human view if desired but should retain separate references-->
          <td>
            <content ID="SystolicAVGBP_1">122</content>/<content ID="DiastolicAVGBP_1">82</content>mm[Hg] </td>
          <td ID="Pulse_1">80 /min</td>
          <td ID="Temp_1">37.2 C</td>
          <td ID="RespRate_1">18 /min</td>
          <td ID="Height_1">170.2 cm</td>
          <td ID="Weight_1">108.8 kg</td>
          <td ID="BMI_1">37.58 kg/m2</td>
          <td ID="SPO2_1">98%</td>
        </tr>
      </tbody>
    </table>
  </text>
    <entry typeCode="DRIV">
      <!-- When a set of vital signs are recorded together, include them in single clustered organizer-->
      <organizer classCode="CLUSTER" moodCode="EVN">
        <templateId root="2.16.840.1.113883.10.20.22.4.26" extension="2015-08-01" />
        <id root="e6c800c4-4a71-41bf-80e2-e741dd1168e9" />
        <code code="46680005" displayName="Vital Signs" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT">
          <translation code="74728-7"
            displayName="Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel"
            codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
        </code>
        <statusCode code="completed" />
        <effectiveTime value="20140520193605-0500" />
        <!-- Each vital sign should be its own component. Note that systolic and diastolic BP must be separate components-->
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="fdbd831b-5919-4f06-9467-76b07022f8e8" />
            <code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Systolic blood pressure" />
            <text>
              <!-- This reference identifies content in human readable formatted text-->
              <reference value="#SystolicBP_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <!-- Example of Value with UCUM unit. Note that metric units used in this example-->
            <value xsi:type="PQ" value="120" unit="mm[Hg]" />
            <!-- Additional information of interpretation and/or reference range may be included but are optional-->
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="553f3f45-9046-4659-b3e7-5de904003550" />
            <code code="8462-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diastolic blood pressure" />
            <text>
              <reference value="#DiastolicBP_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="80" unit="mm[Hg]" />
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="604b2f9e-a3e7-4f4c-a4f8-0022d72dee2b" />
            <code code="96607-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Blood pressure panel mean systolic and mean diastolic" />
            <text>
              <reference value="#AvgBP_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140519193605-0500" />
            <value xsi:type="PQ" nullFlavor="NA" unit="{NA}" />
            <entryRelationship typeCode="COMP">
              <observation classCode="OBS" moodCode="EVN">  
                <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
                <id root="a24910a8-2710-4940-908e-b3d805d5130c" />
                <code code="96608-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="average aystolic blood pressure" />
                <text>
                  <!-- This reference identifies content in human readable formatted text-->
                  <reference value="#SystolicAVGBP_1"/>
                </text>
                <statusCode code="completed" />
                <effectiveTime value="20140519193605-0500" />
                <!-- Example of Value with UCUM unit. Note that metric units used in this example-->
                <value xsi:type="PQ" value="122" unit="mm[Hg]" />
                <!-- Additional information of interpretation and/or reference range may be included but are optional-->
              </observation>
            </entryRelationship>
            <entryRelationship typeCode="COMP">
              <observation classCode="OBS" moodCode="EVN">  
                <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
                <id root="553f3f45-9046-4659-b3e7-5de904003550" />
                <code code="96609-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="average Diastolic blood pressure" />
                <text>
                  <reference value="#DiastolicBP_1"/>
                </text>
                <statusCode code="completed" />
                <effectiveTime value="20140520193605-0500" />
                <value xsi:type="PQ" value="82" unit="mm[Hg]" />
              </observation>
            </entryRelationship>
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="77bfe276-a1dd-4372-9072-e603905acc07" />
            <code code="8867-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Heart rate" />
            <text>
              <reference value="#Pulse_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="80" unit="/min" />
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="24faa204-db62-4610-864f-cb50b650d0fa" />
            <code code="8310-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body temperature" />
            <text>
              <reference value="#Temp_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="37.2" unit="Cel" />
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="79f25395-8ec6-488b-8c05-becc97f79995" />
            <code code="9279-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Respiratory rate" />
            <text>
              <reference value="#RespRate_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="18" unit="/min" />
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="6d3fa9f8-6049-41bd-b0c3-b0196bb6bd37" />
            <code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body height" />
            <text>
              <reference value="#Height_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="170.2" unit="cm" />
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="2594e631-2189-4e72-9dd1-d6769ee2a7be" />
            <code code="29463-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body weight" />
            <text>
              <reference value="#Weight_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="108.863" unit="kg" />
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="5858e765-2ffe-413f-9197-260f2c6e7aa8" />
            <code code="39156-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Body mass index (BMI) [Ratio]" />
            <text>
              <reference value="#BMI_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="37.58" unit="kg/m2" />
          </observation>
        </component>
        <component>
          <observation classCode="OBS" moodCode="EVN">  
            <templateId root="2.16.840.1.113883.10.20.22.4.27" extension="2014-06-09" />
            <id root="4ce6046c-f6e3-41b0-91fc-2d5325f2bbc3" />
            <code code="2710-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="OXYGEN SATURATION" />
            <text>
              <reference value="#SPO2_1"/>
            </text>
            <statusCode code="completed" />
            <effectiveTime value="20140520193605-0500" />
            <value xsi:type="PQ" value="98" unit="%" />
          </observation>
        </component>
      </organizer>
    </entry>
</section>