Template Clinical Presentation Section

Id 2.16.840.1.113883.10.20.22.2.52 Effective Date 2016‑12‑17 06:21:40

Status Draft Version Label 2.1

Name ClinicalPresentationSection Display Name Clinical Presentation Section

Description

This section records the patient’s reason for the patient's visit (as documented by the provider). Local policy determines whether Reason for Visit and Chief Complaint are in separate or combined sections.

Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.52

Classification CDA Section Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 4 templates, Uses 0 templates

Used by	as	Name	Version
2.16.840.1.113883.10.20.22.2.73	Containment	Procedure Activity Procedure (V2) (2.1)	2019‑03‑06 15:51:00
2.16.840.1.113883.10.20.22.2.95		Result Organizer (V3) (2.1)	2019‑04‑03 23:40:21
2.16.840.1.113883.10.20.22.2.47		BC CDA Results Section (entries optional) (V3) (2.1)	2019‑03‑16 19:55:12
2.16.840.1.113883.3.51.60.2.4.1		BC CDA ClinicalDocumentDischargeSummary (V3) (2.1)	2019‑03‑19 14:15:51

Relationship

Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)

ref

ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13)

ref

ccda-

Item DT Card Conf Description Label

cda:section

(Cliion)

cda:templateId

1 … 1

SHALL contain exactly one [1..1] templateId (CONF:81-7836) such that it

CONF7836

@root

uid

1 … 1

2.16.840.1.113883.10.20.6.2.20

CONF0448

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.2.20" (CONF:81-10448).

cda:code

1 … 1

SHALL contain exactly one [1..1] code (CONF:81-15429).

CONF5429

@code

CONF

1 … 1

55108-5

@codeSystem

1 … 1

2.16.840.1.113883.6.1 (LOINC)

cda:title

1 … 1

SHALL contain exactly one [1..1] title (CONF:81-7838).

CONF7838

cda:text

SD.TEXT

1 … 1

SHALL contain exactly one [1..1] text (CONF:81-7839).

CONF7839