Sample Sections for Study

Owned by Suranga Kasthurirathne
Last updated: Sept 03, 2014 by Michael Downey
3 min read

 

The Social History section (obtained via NIST examples)

As per IHE, this section SHALL contain coded entries and SHOULD use the codes specified in the Antepartum Social History Value Set. If the data is not present or not available within the system no entries are required.

So basically, we need to search OMRS for any obs linked to a concept listed on the value set page, and include them in this section.

<component>
				<!--   Social History ******** -->
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
					<!--  ********  Social history section template   ******** -->
					<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" displayName="Social History"/>
					<title>Social History</title>
					<text>
						<table border="1" width="100%">
							<thead>
								<tr>
									<th>Social History Element</th>
									<th>Description</th>
									<th>Effective Dates</th>
								</tr>
							</thead>
							<tbody>
								<tr>
									<td>
										<content ID="soc1"/> smoking</td>
									<td>1 pack per day</td>
									<td>1947 - 1972</td>
								</tr>
								<tr>
									<td>
										<content ID="soc2"/> smoking</td>
									<td>None</td>
									<td>1973 - </td>
								</tr>
								<tr>
									<td>
										<content ID="soc3"/>Alcohol consumption</td>
									<td>None</td>
									<td>1973 - </td>
								</tr>
							</tbody>
						</table>
					</text>
					<entry typeCode="DRIV">
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
							<!--  ********  Social history observation template   ******** -->
							<id root="9b56c25d-9104-45ee-9fa4-e0f3afaa01c1"/>
							<code code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking">
								<originalText>
									<reference value="#soc1"/>
								</originalText>
							</code>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="1947"/>
								<high value="1972"/>
							</effectiveTime>
							<value xsi:type="ST">1 pack per day</value>
						</observation>
					</entry>
					<entry typeCode="DRIV">
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
							<!--  ********  Social history observation template   ******** -->
							<id root="45efb604-7049-4a2e-ad33-d38556c9636c"/>
							<code code="230056004" codeSystem="2.16.840.1.113883.6.96" displayName="Cigarette smoking">
								<originalText>
									<reference value="#soc2"/>
								</originalText>
							</code>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="1973"/>
							</effectiveTime>
							<value xsi:type="ST">None</value>
						</observation>
					</entry>
					<entry typeCode="DRIV">
						<observation classCode="OBS" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.38"/>
							<!--  ********  Social history observation template   ******** -->
							<id root="37f76c51-6411-4e1d-8a37-957fd49d2cef"/>
							<code code="160573003" codeSystem="2.16.840.1.113883.6.96" displayName="Alcohol consumption">
								<originalText>
									<reference value="#soc3"/>
								</originalText>
							</code>
							<statusCode code="completed"/>
							<effectiveTime>
								<low value="1973"/>
							</effectiveTime>
							<value xsi:type="ST">None</value>
						</observation>
					</entry>
				</section>
			</component>
			<!--

 

The Vital Signs section : (obtained via NIST examples)

Use this model, and look for the specific terms listed here.

			<component>
				<section>
					<templateId root="2.16.840.1.113883.10.20.22.2.4.1"/>
					<code code="8716-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="VITAL SIGNS"/>
					<title>Vital Signs</title>
					<text>
						<table border="1" width="100%">
							<thead>
								<tr>
									<th align="right">Date / Time: </th>
									<th>Nov 14, 1999</th>
									<th>April 7, 2000</th>
								</tr>
							</thead>
							<tbody>
								<tr>
									<th align="left">Height</th>
									<td>
										<content ID="vit1">177 cm</content>
									</td>
									<td>
										<content ID="vit2">177 cm</content>
									</td>
								</tr>
								<tr>
									<th align="left">Weight</th>
									<td>
										<content ID="vit3">86 kg</content>
									</td>
									<td>
										<content ID="vit4">88 kg</content>
									</td>
								</tr>
								<tr>
									<th align="left">Blood Pressure</th>
									<td>
										<content ID="vit5">132/86 mmHg</content>
									</td>
									<td>
										<content ID="vit6">145/88 mmHg</content>
									</td>
								</tr>
							</tbody>
						</table>
					</text>
					<entry typeCode="DRIV">
						<organizer classCode="CLUSTER" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.26"/>
							<!-- Vital signs organizer template -->
							<id root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
							<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED -CT" displayName="Vital signs"/>
							<statusCode code="completed"/>
							<effectiveTime value="19991114"/>
							<component>
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
									<!-- Vital Sign Observation template -->
									<id root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
									<code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Height"/>
									<text>
										<reference value="#vit1"/>
									</text>
									<statusCode code="completed"/>
									<effectiveTime value="19991114"/>
									<value xsi:type="PQ" value="177" unit="cm"/>
									<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
								</observation>
							</component>
							<component>
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
									<!-- Vital Sign Observation template -->
									<id root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
									<code code="3141-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Body Weight - Measured"/>
									<text>
										<reference value="#vit4"/>
									</text>
									<statusCode code="completed"/>
									<effectiveTime value="19991114"/>
									<value xsi:type="PQ" value="86" unit="kg"/>
									<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
								</observation>
							</component>
							<component>
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
									<!-- Vital Sign Observation template -->
									<id root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
									<code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Intravascular Systolic"/>
									<text>
										<reference value="#vit5"/>
									</text>
									<statusCode code="completed"/>
									<effectiveTime value="19991114"/>
									<value xsi:type="PQ" value="132" unit="mm[Hg]"/>
									<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
								</observation>
							</component>
						</organizer>
					</entry>
					<entry typeCode="DRIV">
						<organizer classCode="CLUSTER" moodCode="EVN">
							<templateId root="2.16.840.1.113883.10.20.22.4.26"/>
							<!-- Vital signs organizer template -->
							<id root="c6f88320-67ad-11db-bd13-0800200c9a66"/>
							<code code="46680005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED -CT" displayName="Vital signs"/>
							<statusCode code="completed"/>
							<effectiveTime value="20000407"/>
							<component>
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
									<!-- Vital Sign Observation template -->
									<id root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
									<code code="8302-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Height"/>
									<text>
										<reference value="#vit2"/>
									</text>
									<statusCode code="completed"/>
									<effectiveTime value="20000407"/>
									<value xsi:type="PQ" value="177" unit="cm"/>
									<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
								</observation>
							</component>
							<component>
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
									<!-- Vital Sign Observation template -->
									<id root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
									<code code="3141-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Patient Body Weight - Measured"/>
									<text>
										<reference value="#vit4"/>
									</text>
									<statusCode code="completed"/>
									<effectiveTime value="20000407"/>
									<value xsi:type="PQ" value="88" unit="kg"/>
									<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
								</observation>
							</component>
							<component>
								<observation classCode="OBS" moodCode="EVN">
									<templateId root="2.16.840.1.113883.10.20.22.4.27"/>
									<!-- Vital Sign Observation template -->
									<id root="c6f88321-67ad-11db-bd13-0800200c9a66"/>
									<code code="8480-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Intravascular Systolic"/>
									<text>
										<reference value="#vit6"/>
									</text>
									<statusCode code="completed"/>
									<effectiveTime value="20000407"/>
									<value xsi:type="PQ" value="145" unit="mm[Hg]"/>
									<interpretationCode code="N" codeSystem="2.16.840.1.113883.5.83"/>
								</observation>
							</component>
						</organizer>
					</entry>
				</section>
			</component>

 

History of present illness

How to represent the observation date ?

			<component>
				<section>
					<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>
					<code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="10164-2" displayName="HISTORY OF PRESENT ILLNESS"/>
					<title>HISTORY OF PRESENT ILLNESS</title>
					<text>
						<paragraph>This patient was only recently discharged for a recurrent GI bleed as described below.</paragraph>
						<paragraph>He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On 
							 he was hypotensive in the 80?s resolved after .... .... .... </paragraph>
						<paragraph>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40.</paragraph>
						<paragraph>He was transfused with 6 units of packed red blood cells with .... .... ....</paragraph>
						<paragraph>GI evaluation 12 September: Colonoscopy showed single red clot in .... .... ....</paragraph>
					</text>
				</section>
			</component>