Active| Used by 0 transactions and 0 templates, Uses 27 templates | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Chief Complaint Section (1.1)| Item | DT | Card | Conf | Description | Label |
|---|---|---|---|---|---|
| cda:ClinicalDocument | MU2‑056 | ||||
| cda:templateId | II | 1 … 1 | M | MU2‑056 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.8 | |
| cda:component | 1 … 1 | M | MU2‑056 | ||
| cda:structuredBody | 1 … 1 | M | MU2‑056 | ||
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31) | MU2‑056 | |
| cda:component | 0 … 1 | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.5 Hospital Course Section (2013‑01‑31) | MU2‑035 | ||
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.24 Hospital Discharge Diagnosis Section (2013‑01‑31) | MU2‑056 | |
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.11 Hospital Discharge Medications Section (entries optional) (2013‑01‑31) | MU2‑056 | |
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31) | MU2‑056 | |
| cda:component | 0 … 1 | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.33 Discharge Diet Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (2013‑01‑31) | MU2‑056 | |
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 0 … 1 | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 0 … 1 | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.26 Hospital Discharge Physical Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.16 Hospital Discharge Studies Summary Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (2013‑01‑31) | MU2‑056 | |
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (2013‑01‑31) | MU2‑056 | |
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (2013‑01‑31) | MU2‑056 | |
| Choice | 1 … * | Elements to choose from:
| |||
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2013‑01‑31) | MU2‑050 | ||
| cda:component | 0 … 1 | Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31) | MU2‑050 | ||
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2013‑01‑31) | MU2‑050 | ||
| cda:component | 0 … 1 | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.17 MU2 Social History Section (DYNAMIC) | MU2‑056 | |
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31) | MU2‑056 | |
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.42 Hospital Consultations Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (2013‑01‑31) | MU2‑056 | |
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.43 Hospital Admission Diagnosis Section (2013‑01‑31) | MU2‑056 | ||
| cda:component | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.2.44 Hospital Admission Medications Section (entries optional) (2013‑01‑31) | MU2‑056 | ||
| cda:component | 1 … 1 | M | Contains 2.16.840.1.113883.10.20.22.2.3.1 Results Section (entries required) (2013‑01‑31) | MU2‑034 | |
| cda:component | 1 … 1 | M | Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 Reason for Referral Section (2013‑01‑31) | MU2‑034 | |
| Schematron assert | role |  error | |||
| test | //hl7:section[hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.17']/hl7:entry | ||||
| Message | Social History Section SHALL contains entries (paragraph 4.2.3, MU2-034) | ||||
| Schematron assert | role | error | |||
| test | every $section in //hl7:section[hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.6' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.1' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.2' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.5' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.7' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.3'] satisfies $section/hl7:entry | ||||
| Message | Entries in Consultation Note are required by MU2 for Allergies, Medications, Immunizations, Problems, Procedures, Laboratory Tests, and Values/Results of Laboratory Tests, in Consultation Note (paragraph 4.2.2, MU2-036) | ||||