Volet de Synthèse Médicale (International Patient Summary - CDA)
0.1.0 - ci-build
Volet de Synthèse Médicale (International Patient Summary - CDA) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://interop.esante.gouv.fr/ig/cda/fr-patient-summary/StructureDefinition/fr-cda-clinical-document-ips | Version: 0.1.0 | ||||
| Draft as of 2026-10-22 | Computable Name: FRCDAClinicalDocumentIPS | ||||
L'élément de l'en-tête CDA 'ClinicalDocument' est l’élément racine d’un document médical IPS (International Patient Summary).
Usages:
You can also check for usages in the FHIR IG Statistics
Description Differentials, Snapshots, and other representations.
This structure is derived from FRCDAClinicalDocument
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() |
|---|---|---|---|---|
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1..1 | FRCDAClinicalDocument(0.1.0) | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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4..* | II | Déclarations de conformité. Slice: Unordered, Open by value:root Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
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1..1 | II | Conformité spécifications HL7 France | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.2.8.2.1 (extensions allowed) | |
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1..1 | II | Conformité spécifications au CI-SIS | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.1.1 (extensions allowed) | |
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1..1 | II | Conformité spécifications IHE PCC IPS | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.10.22.1.1 (extensions allowed) | |
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1..1 | II | Conformité au Volet de l'International Patient Summary fr (IPS-FR_2024.01) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.1.51 (extensions allowed) | |
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0..1 | st(2.0.3-sd) | Required Pattern: 2024.01 (extensions allowed) | |
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1..1 | CE | Type de document : Synthèse Médicale (code LOINC 60591-5). | |
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0..1 | cs(2.0.3-sd) | Required Pattern: 60591-5 (extensions allowed) | |
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0..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.6.1 (extensions allowed) | |
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0..1 | st(2.0.3-sd) | Required Pattern: LOINC (extensions allowed) | |
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0..1 | st(2.0.3-sd) | Required Pattern: Synthèse médicale (extensions allowed) | |
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1..1 | ST | Titre du document : SYNTHESE MEDICALE. | |
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1..1 | TS | Date de création du document Synthèse Médicale. | |
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0..* | FRCDAParticipantEntete(0.1.0) | Participant, différent de l'auteur, du responsable, de l'opérateur de saisie, de l'informateur ou du destinataire. Slice: Unordered, Open by value:functionCode.code, value:typeCode Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
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0..1 | FRCDAParticipantEntete(0.1.0) | Médecin traitant | |
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1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: INF (extensions allowed) | |
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1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: PCP (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.5.88 (extensions allowed) | |
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0..1 | FRCDAParticipantEntete(0.1.0) | [DLU] Contact 24h/24h en EHPAD | |
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1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: PRF (extensions allowed) | |
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1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: CORRE (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
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0..1 | FRCDAParticipantEntete(0.1.0) | [DLU] Établissement de santé de préférence | |
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1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: INF (extensions allowed) | |
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1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: ES-PREF (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
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0..* | FRCDAParticipantEntete(0.1.0) | Établissement de santé de référence | |
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1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: INF (extensions allowed) | |
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1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: ES-REF (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
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0..* | FRCDAParticipantEntete(0.1.0) | Autre professionnel de santé | |
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1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: PRF (extensions allowed) | |
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1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: 353 (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.6.1.107 (extensions allowed) | |
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0..* | FRCDAParticipantEntete(0.1.0) | Autre correspondant participant à la prise en charge ou au suivi du patient | |
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1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: CON (extensions allowed) | |
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1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: CORRE (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
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1..1 | FRCDADocumentationOf(0.1.0) | Evènement documenté et notamment le cadre d'exercice. | |
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0..1 | StructuredBody | Structure du document IPS. | |
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5..* | InfrastructureRoot | Composants contenant les sections du document IPS. Slice: Unordered, Open by value:section.code.code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
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1..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionProblemesActifs(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionAntecedentsMedicaux(0.1.0) | ||
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1..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionHistoriqueDesActes(0.1.0) | ||
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1..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionAllergiesEtHypersensibilites(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionEffetsIndesirables(0.1.0) | ||
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C | 1..1 | InfrastructureRoot | |
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1..1 | FRCDASectionTraitements(0.1.0) | ||
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1..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionDispositifsMedicaux(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionPointsDeVigilancesNonCode(0.1.0) | ||
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C | 0..1 | InfrastructureRoot | |
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1..1 | FRCDASectionStatutFonctionnel(0.1.0) | ||
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0..* | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation Slice: Unordered, Open by value:organizer.code.code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
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Content/Rules for all slices | |||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationEtatPsychiqueDLU(0.1.0) | ||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationHandicapsDLU(0.1.0) | ||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationDeplacementsDLU(0.1.0) | ||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationAutresRisquesDLU(0.1.0) | ||
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0..2 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationScoreDLU(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionSignesVitaux(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionHabitusModeDeVie(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionAntecedentsFamiliaux(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionFacteursDeRisqueProfessionnelsNonCode(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionVaccinations(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionHistoriqueDesGrossesses(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionPlanDeSoins(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionDirectivesAnticipees(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionResultats(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionDocumentsAjoutes(0.1.0) | ||
Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| dlu-statut-fonctionnel-evaluations | error | ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel | Pour la synthèse médicale d'un DLU, la liste des évaluations est fixée : dès qu'un groupe d'évaluations LOINC propre au DLU est présent (état psychique 54511-1, handicaps / déficits 52621-0, déplacements / transferts 32452-5), les trois groupes doivent être présents. Le groupe « autres risques » n'est pas vérifié ici : le tableau du volet (GEN-092.01.24) et l'exemple publié par l'ANS (GEN-092.04.24) divergent sur son code |
(section.entry.organizer.code.code contains '54511-1' or section.entry.organizer.code.code contains '52621-0' or section.entry.organizer.code.code contains '32452-5') implies (section.entry.organizer.code.code contains '54511-1' and section.entry.organizer.code.code contains '52621-0' and section.entry.organizer.code.code contains '32452-5')
|
| dlu-traitement-type | error | ClinicalDocument.component.structuredBody.component:sectionTraitements | Dans la section Traitements, chaque traitement porte exactement un templateId parmi traitement au long cours (1.2.250.1.213.1.1.3.42.3) et traitement aigu (1.2.250.1.213.1.1.3.42.4). Pour une synthèse médicale hors DLU, seul le traitement au long cours est utilisé |
section.entry.substanceAdministration.all(templateId.where(root = '1.2.250.1.213.1.1.3.42.3').count() + templateId.where(root = '1.2.250.1.213.1.1.3.42.4').count() = 1)
|
| Path | Status | Usage | ValueSet | Version | Source |
| ClinicalDocument.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.classCode | Base | example | CDAActClass | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.moodCode | Base | required | CDAActMood | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteSpecificationsHL7.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteSpecificationsCISIS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteSpecificationsIHEPCCIPS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteVoletIPS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.code | Base | example | FHIR Document Type Codes | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.code.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.sdtcStatusCode | Base | required | ActStatus | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.languageCode | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.participant:medecinTraitant.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:medecinTraitant.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:medecinTraitant.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:medecinTraitant.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:contactEHPAD.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:contactEHPAD.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:contactEHPAD.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:contactEHPAD.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabPreference.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabPreference.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabPreference.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:etabPreference.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabReference.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabReference.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabReference.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:etabReference.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autrePS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autrePS.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autrePS.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:autrePS.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autreCorrespondant.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autreCorrespondant.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autreCorrespondant.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:autreCorrespondant.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.typeCode | Base | required | ActRelationshipHasComponent | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.classCode | Base | required | ActClassRecordOrganizer | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.moodCode | Base | required | CDAActMood | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.languageCode | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.component.structuredBody.component.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionProblemesActifs.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionProblemesActifs.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentsMedicaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentsMedicaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesActes.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesActes.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAllergiesEtHypersensibilites.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAllergiesEtHypersensibilites.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionEffetsIndesirables.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionEffetsIndesirables.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionTraitements.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionTraitements.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDispositifsMedicaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDispositifsMedicaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPointsDeVigilancesNonCode.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPointsDeVigilancesNonCode.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.templateId:frSectionStatutFonctionnel.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.templateId:IPSSectionFunctionalStatus.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.templateId:ccdSectionFunctionalStatus.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.classCode | Base | required | ActClassRecordOrganizer | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.moodCode | Base | required | CDAActMood | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.code.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.languageCode | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.component.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.component.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionSignesVitaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionSignesVitaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHabitusModeDeVie.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHabitusModeDeVie.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentFamiliaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentFamiliaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionFacteursDeRisqueProfessionnelsNonCode.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionFacteursDeRisqueProfessionnelsNonCode.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionVaccinations.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionVaccinations.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesGrossesses.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesGrossesses.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPlanDeSoins.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPlanDeSoins.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDirectivesAnticipees.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDirectivesAnticipees.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionResultats.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionResultats.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDocumentsAjoutes.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDocumentsAjoutes.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| FRCDAPerformerRequire | error | ClinicalDocument | performer est obligatoire et son attribut nullFlavor interdit pour l’évènement documenté principal |
documentationOf.serviceEvent.performer.count() >= 1
|
| II-1 | error | ClinicalDocument.typeId, ClinicalDocument.participant:medecinTraitant.typeId, ClinicalDocument.participant:contactEHPAD.typeId, ClinicalDocument.participant:etabPreference.typeId, ClinicalDocument.participant:etabReference.typeId, ClinicalDocument.participant:autrePS.typeId, ClinicalDocument.participant:autreCorrespondant.typeId, ClinicalDocument.component.typeId, ClinicalDocument.component.structuredBody.typeId, ClinicalDocument.component.structuredBody.component.typeId, ClinicalDocument.component.structuredBody.component:sectionProblemesActifs.typeId, ClinicalDocument.component.structuredBody.component:sectionAntecedentsMedicaux.typeId, ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesActes.typeId, ClinicalDocument.component.structuredBody.component:sectionAllergiesEtHypersensibilites.typeId, ClinicalDocument.component.structuredBody.component:sectionEffetsIndesirables.typeId, ClinicalDocument.component.structuredBody.component:sectionTraitements.typeId, ClinicalDocument.component.structuredBody.component:sectionDispositifsMedicaux.typeId, ClinicalDocument.component.structuredBody.component:sectionPointsDeVigilancesNonCode.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.component.typeId, ClinicalDocument.component.structuredBody.component:sectionSignesVitaux.typeId, ClinicalDocument.component.structuredBody.component:sectionHabitusModeDeVie.typeId, ClinicalDocument.component.structuredBody.component:sectionAntecedentFamiliaux.typeId, ClinicalDocument.component.structuredBody.component:sectionFacteursDeRisqueProfessionnelsNonCode.typeId, ClinicalDocument.component.structuredBody.component:sectionVaccinations.typeId, ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesGrossesses.typeId, ClinicalDocument.component.structuredBody.component:sectionPlanDeSoins.typeId, ClinicalDocument.component.structuredBody.component:sectionDirectivesAnticipees.typeId, ClinicalDocument.component.structuredBody.component:sectionResultats.typeId, ClinicalDocument.component.structuredBody.component:sectionDocumentsAjoutes.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| dlu-statut-fonctionnel-evaluations | error | ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel | Pour la synthèse médicale d'un DLU, la liste des évaluations est fixée : dès qu'un groupe d'évaluations LOINC propre au DLU est présent (état psychique 54511-1, handicaps / déficits 52621-0, déplacements / transferts 32452-5), les trois groupes doivent être présents. Le groupe « autres risques » n'est pas vérifié ici : le tableau du volet (GEN-092.01.24) et l'exemple publié par l'ANS (GEN-092.04.24) divergent sur son code |
(section.entry.organizer.code.code contains '54511-1' or section.entry.organizer.code.code contains '52621-0' or section.entry.organizer.code.code contains '32452-5') implies (section.entry.organizer.code.code contains '54511-1' and section.entry.organizer.code.code contains '52621-0' and section.entry.organizer.code.code contains '32452-5')
|
| dlu-traitement-type | error | ClinicalDocument.component.structuredBody.component:sectionTraitements | Dans la section Traitements, chaque traitement porte exactement un templateId parmi traitement au long cours (1.2.250.1.213.1.1.3.42.3) et traitement aigu (1.2.250.1.213.1.1.3.42.4). Pour une synthèse médicale hors DLU, seul le traitement au long cours est utilisé |
section.entry.substanceAdministration.all(templateId.where(root = '1.2.250.1.213.1.1.3.42.3').count() + templateId.where(root = '1.2.250.1.213.1.1.3.42.4').count() = 1)
|
This structure is derived from FRCDAClinicalDocument
Summary
Mandatory: 8 elements(5 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from FRCDAClinicalDocument
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() |
|---|---|---|---|---|
![]() |
1..1 | FRCDAClinicalDocument(0.1.0) | XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
![]() ![]() |
4..* | II | Déclarations de conformité. Slice: Unordered, Open by value:root Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
![]() ![]() ![]() |
1..1 | II | Conformité spécifications HL7 France | |
![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.2.8.2.1 (extensions allowed) | |
![]() ![]() ![]() |
1..1 | II | Conformité spécifications au CI-SIS | |
![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.1.1 (extensions allowed) | |
![]() ![]() ![]() |
1..1 | II | Conformité spécifications IHE PCC IPS | |
![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.10.22.1.1 (extensions allowed) | |
![]() ![]() ![]() |
1..1 | II | Conformité au Volet de l'International Patient Summary fr (IPS-FR_2024.01) | |
![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.1.51 (extensions allowed) | |
![]() ![]() ![]() ![]() |
0..1 | st(2.0.3-sd) | Required Pattern: 2024.01 (extensions allowed) | |
![]() ![]() |
1..1 | CE | Type de document : Synthèse Médicale (code LOINC 60591-5). | |
![]() ![]() ![]() |
0..1 | cs(2.0.3-sd) | Required Pattern: 60591-5 (extensions allowed) | |
![]() ![]() ![]() |
0..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.6.1 (extensions allowed) | |
![]() ![]() ![]() |
0..1 | st(2.0.3-sd) | Required Pattern: LOINC (extensions allowed) | |
![]() ![]() ![]() |
0..1 | st(2.0.3-sd) | Required Pattern: Synthèse médicale (extensions allowed) | |
![]() ![]() |
1..1 | ST | Titre du document : SYNTHESE MEDICALE. | |
![]() ![]() |
1..1 | TS | Date de création du document Synthèse Médicale. | |
![]() ![]() |
0..* | FRCDAParticipantEntete(0.1.0) | Participant, différent de l'auteur, du responsable, de l'opérateur de saisie, de l'informateur ou du destinataire. Slice: Unordered, Open by value:functionCode.code, value:typeCode Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
![]() ![]() ![]() |
0..1 | FRCDAParticipantEntete(0.1.0) | Médecin traitant | |
![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: INF (extensions allowed) | |
![]() ![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: PCP (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 2.16.840.1.113883.5.88 (extensions allowed) | |
![]() ![]() ![]() |
0..1 | FRCDAParticipantEntete(0.1.0) | [DLU] Contact 24h/24h en EHPAD | |
![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: PRF (extensions allowed) | |
![]() ![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: CORRE (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
![]() ![]() ![]() |
0..1 | FRCDAParticipantEntete(0.1.0) | [DLU] Établissement de santé de préférence | |
![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: INF (extensions allowed) | |
![]() ![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: ES-PREF (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
![]() ![]() ![]() |
0..* | FRCDAParticipantEntete(0.1.0) | Établissement de santé de référence | |
![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: INF (extensions allowed) | |
![]() ![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: ES-REF (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
![]() ![]() ![]() |
0..* | FRCDAParticipantEntete(0.1.0) | Autre professionnel de santé | |
![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: PRF (extensions allowed) | |
![]() ![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: 353 (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.6.1.107 (extensions allowed) | |
![]() ![]() ![]() |
0..* | FRCDAParticipantEntete(0.1.0) | Autre correspondant participant à la prise en charge ou au suivi du patient | |
![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Type de participation Required Pattern: CON (extensions allowed) | |
![]() ![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() ![]() |
1..1 | cs(2.0.3-sd) | Code issu du JDV_J47_FunctionCode_CISIS (1.2.250.1.213.1.1.5.124) Required Pattern: CORRE (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Required Pattern: 1.2.250.1.213.1.1.4.2.280 (extensions allowed) | |
![]() ![]() |
1..1 | FRCDADocumentationOf(0.1.0) | Evènement documenté et notamment le cadre d'exercice. | |
![]() ![]() |
||||
![]() ![]() ![]() |
0..1 | StructuredBody | Structure du document IPS. | |
![]() ![]() ![]() ![]() |
5..* | InfrastructureRoot | Composants contenant les sections du document IPS. Slice: Unordered, Open by value:section.code.code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
![]() ![]() ![]() ![]() ![]() |
1..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionProblemesActifs(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionAntecedentsMedicaux(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
1..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionHistoriqueDesActes(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
1..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionAllergiesEtHypersensibilites(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionEffetsIndesirables(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
C | 1..1 | InfrastructureRoot | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionTraitements(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
1..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionDispositifsMedicaux(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionPointsDeVigilancesNonCode(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | InfrastructureRoot | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionStatutFonctionnel(0.1.0) | ||
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0..* | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation Slice: Unordered, Open by value:organizer.code.code Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
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Content/Rules for all slices | |||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationEtatPsychiqueDLU(0.1.0) | ||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationHandicapsDLU(0.1.0) | ||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationDeplacementsDLU(0.1.0) | ||
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0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationAutresRisquesDLU(0.1.0) | ||
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0..2 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
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0..1 | FRCDAGroupeEvaluationScoreDLU(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionSignesVitaux(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionHabitusModeDeVie(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionAntecedentsFamiliaux(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionFacteursDeRisqueProfessionnelsNonCode(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionVaccinations(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionHistoriqueDesGrossesses(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionPlanDeSoins(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionDirectivesAnticipees(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionResultats(0.1.0) | ||
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0..1 | InfrastructureRoot | ||
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1..1 | FRCDASectionDocumentsAjoutes(0.1.0) | ||
Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| dlu-statut-fonctionnel-evaluations | error | ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel | Pour la synthèse médicale d'un DLU, la liste des évaluations est fixée : dès qu'un groupe d'évaluations LOINC propre au DLU est présent (état psychique 54511-1, handicaps / déficits 52621-0, déplacements / transferts 32452-5), les trois groupes doivent être présents. Le groupe « autres risques » n'est pas vérifié ici : le tableau du volet (GEN-092.01.24) et l'exemple publié par l'ANS (GEN-092.04.24) divergent sur son code |
(section.entry.organizer.code.code contains '54511-1' or section.entry.organizer.code.code contains '52621-0' or section.entry.organizer.code.code contains '32452-5') implies (section.entry.organizer.code.code contains '54511-1' and section.entry.organizer.code.code contains '52621-0' and section.entry.organizer.code.code contains '32452-5')
|
| dlu-traitement-type | error | ClinicalDocument.component.structuredBody.component:sectionTraitements | Dans la section Traitements, chaque traitement porte exactement un templateId parmi traitement au long cours (1.2.250.1.213.1.1.3.42.3) et traitement aigu (1.2.250.1.213.1.1.3.42.4). Pour une synthèse médicale hors DLU, seul le traitement au long cours est utilisé |
section.entry.substanceAdministration.all(templateId.where(root = '1.2.250.1.213.1.1.3.42.3').count() + templateId.where(root = '1.2.250.1.213.1.1.3.42.4').count() = 1)
|
Snapshot ViewView
| Path | Status | Usage | ValueSet | Version | Source |
| ClinicalDocument.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.classCode | Base | example | CDAActClass | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.moodCode | Base | required | CDAActMood | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteSpecificationsHL7.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteSpecificationsCISIS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteSpecificationsIHEPCCIPS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.templateId:conformiteVoletIPS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.code | Base | example | FHIR Document Type Codes | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.code.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.sdtcStatusCode | Base | required | ActStatus | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.languageCode | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.participant:medecinTraitant.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:medecinTraitant.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:medecinTraitant.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:medecinTraitant.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:contactEHPAD.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:contactEHPAD.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:contactEHPAD.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:contactEHPAD.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabPreference.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabPreference.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabPreference.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:etabPreference.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabReference.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabReference.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:etabReference.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:etabReference.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autrePS.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autrePS.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autrePS.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:autrePS.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autreCorrespondant.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autreCorrespondant.typeCode | Base | required | CDAParticipationType | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.participant:autreCorrespondant.functionCode.code | Base | required | JDV_J47_FunctionCode_CISIS | 📍20250523120000 | Terminologies de Santé v1.14 |
| ClinicalDocument.participant:autreCorrespondant.time.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.typeCode | Base | required | ActRelationshipHasComponent | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.classCode | Base | required | ActClassRecordOrganizer | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.moodCode | Base | required | CDAActMood | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.languageCode | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.component.structuredBody.component.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionProblemesActifs.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionProblemesActifs.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentsMedicaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentsMedicaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesActes.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesActes.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAllergiesEtHypersensibilites.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAllergiesEtHypersensibilites.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionEffetsIndesirables.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionEffetsIndesirables.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionTraitements.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionTraitements.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDispositifsMedicaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDispositifsMedicaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPointsDeVigilancesNonCode.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPointsDeVigilancesNonCode.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.templateId:frSectionStatutFonctionnel.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.templateId:IPSSectionFunctionalStatus.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.templateId:ccdSectionFunctionalStatus.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.classCode | Base | required | ActClassRecordOrganizer | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.moodCode | Base | required | CDAActMood | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.code.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.languageCode | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.typeCode | Base | required | x_ActRelationshipEntry | 📍3.0.0 | THO v7.4 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.component.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.component.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionSignesVitaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionSignesVitaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHabitusModeDeVie.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHabitusModeDeVie.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentFamiliaux.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionAntecedentFamiliaux.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionFacteursDeRisqueProfessionnelsNonCode.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionFacteursDeRisqueProfessionnelsNonCode.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionVaccinations.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionVaccinations.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesGrossesses.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesGrossesses.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPlanDeSoins.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionPlanDeSoins.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDirectivesAnticipees.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDirectivesAnticipees.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionResultats.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionResultats.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDocumentsAjoutes.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| ClinicalDocument.component.structuredBody.component:sectionDocumentsAjoutes.typeId.nullFlavor | Base | required | CDANullFlavor | 📍2.0.3-sd | Clinical Document Architecture v2.0 |
| Id | Grade | Path(s) | Description | Expression |
| FRCDAPerformerRequire | error | ClinicalDocument | performer est obligatoire et son attribut nullFlavor interdit pour l’évènement documenté principal |
documentationOf.serviceEvent.performer.count() >= 1
|
| II-1 | error | ClinicalDocument.typeId, ClinicalDocument.participant:medecinTraitant.typeId, ClinicalDocument.participant:contactEHPAD.typeId, ClinicalDocument.participant:etabPreference.typeId, ClinicalDocument.participant:etabReference.typeId, ClinicalDocument.participant:autrePS.typeId, ClinicalDocument.participant:autreCorrespondant.typeId, ClinicalDocument.component.typeId, ClinicalDocument.component.structuredBody.typeId, ClinicalDocument.component.structuredBody.component.typeId, ClinicalDocument.component.structuredBody.component:sectionProblemesActifs.typeId, ClinicalDocument.component.structuredBody.component:sectionAntecedentsMedicaux.typeId, ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesActes.typeId, ClinicalDocument.component.structuredBody.component:sectionAllergiesEtHypersensibilites.typeId, ClinicalDocument.component.structuredBody.component:sectionEffetsIndesirables.typeId, ClinicalDocument.component.structuredBody.component:sectionTraitements.typeId, ClinicalDocument.component.structuredBody.component:sectionDispositifsMedicaux.typeId, ClinicalDocument.component.structuredBody.component:sectionPointsDeVigilancesNonCode.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:etatPsychique.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:handicapsDeficits.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:deplacements.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:autresRisques.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.entry:scores.typeId, ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel.section.component.typeId, ClinicalDocument.component.structuredBody.component:sectionSignesVitaux.typeId, ClinicalDocument.component.structuredBody.component:sectionHabitusModeDeVie.typeId, ClinicalDocument.component.structuredBody.component:sectionAntecedentFamiliaux.typeId, ClinicalDocument.component.structuredBody.component:sectionFacteursDeRisqueProfessionnelsNonCode.typeId, ClinicalDocument.component.structuredBody.component:sectionVaccinations.typeId, ClinicalDocument.component.structuredBody.component:sectionHistoriqueDesGrossesses.typeId, ClinicalDocument.component.structuredBody.component:sectionPlanDeSoins.typeId, ClinicalDocument.component.structuredBody.component:sectionDirectivesAnticipees.typeId, ClinicalDocument.component.structuredBody.component:sectionResultats.typeId, ClinicalDocument.component.structuredBody.component:sectionDocumentsAjoutes.typeId | An II instance must have either a root or an nullFlavor. |
root.exists() or nullFlavor.exists()
|
| dlu-statut-fonctionnel-evaluations | error | ClinicalDocument.component.structuredBody.component:sectionStatutFonctionnel | Pour la synthèse médicale d'un DLU, la liste des évaluations est fixée : dès qu'un groupe d'évaluations LOINC propre au DLU est présent (état psychique 54511-1, handicaps / déficits 52621-0, déplacements / transferts 32452-5), les trois groupes doivent être présents. Le groupe « autres risques » n'est pas vérifié ici : le tableau du volet (GEN-092.01.24) et l'exemple publié par l'ANS (GEN-092.04.24) divergent sur son code |
(section.entry.organizer.code.code contains '54511-1' or section.entry.organizer.code.code contains '52621-0' or section.entry.organizer.code.code contains '32452-5') implies (section.entry.organizer.code.code contains '54511-1' and section.entry.organizer.code.code contains '52621-0' and section.entry.organizer.code.code contains '32452-5')
|
| dlu-traitement-type | error | ClinicalDocument.component.structuredBody.component:sectionTraitements | Dans la section Traitements, chaque traitement porte exactement un templateId parmi traitement au long cours (1.2.250.1.213.1.1.3.42.3) et traitement aigu (1.2.250.1.213.1.1.3.42.4). Pour une synthèse médicale hors DLU, seul le traitement au long cours est utilisé |
section.entry.substanceAdministration.all(templateId.where(root = '1.2.250.1.213.1.1.3.42.3').count() + templateId.where(root = '1.2.250.1.213.1.1.3.42.4').count() = 1)
|
This structure is derived from FRCDAClinicalDocument
Summary
Mandatory: 8 elements(5 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: