HL7 FHIR Profile: Skin and Wound Assessment, Release 1 (For Comment)

ClinicalNoteModel

 

The official URL for this logical model is: 

http://hl7.org/fhir/us/sw/StructureDefinition/cimi-statement-ClinicalNote-model

An entry concerning a patient where the result is a narrative text.

This logical model was published on Fri Aug 17 00:00:00 EDT 2018 as a draft by HL7 Patient Care and Clinical Information Modeling Initiative Work Groups.

View the corresponding ClinicalNoteProfile profile.

NameFlagsCard.TypeDescription & Constraintsdoco
.. cimi-statement-ClinicalNote-model 0..*
... personOfRecord 1..1Reference(SW Person Logical Model)The person this entry belongs to.
... recorded 0..1AttributionModelThe person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
... signed 0..1AttributionModelProvenance information specific to the signing of the clinical statement.
... additionalText 1..1stringA text note containing additional details, explanation, description, comment, or summarization. Details can discuss, support, explain changes to, or dispute information.
... contextCode 0..1CodingCode representing the sense in which the statement is interpreted, for example, the degree of presence in a PresenceStatement.
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
.... version Σ0..1stringVersion of the system - if relevant
.... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 424975005
.... display Σ0..1stringRepresentation defined by the system
.... userSelected Σ0..1booleanIf this coding was chosen directly by the user
... statementTopic 0..1StatementTopicModelCompositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement.
... encounter 0..1EncounterModelA description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
... interpretation 0..1CodingA clinical interpretation of a finding (applies to both assertions and observation).
Binding: Observation Interpretation Codes (extensible)
... relevantTime 0..1dateTime, TimePeriodModelThe time or time period that the finding addresses.
... findingMethod 0..1CodingThe technique used to create the finding, for example, the specific imaging technical, lab test code, or assessment vehicle.
Binding: SW FindingMethodVS ValueSet (preferred)
... media 0..*MediaModelA file that contains audio, video, image, or similar content.

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL)

 

Terminology Bindings

PathNameConformanceValueSet
cimi-statement-ClinicalNote-model.interpretationObservation Interpretation CodesextensibleObservation Interpretation Codes
cimi-statement-ClinicalNote-model.findingMethodSW FindingMethodVS ValueSetpreferredFindingMethodVS