Volet de Synthèse Médicale (International Patient Summary - CDA)
0.1.0 - ci-build
Volet de Synthèse Médicale (International Patient Summary - CDA) - version de développement local (intégration continue v0.1.0) construite par les outils de publication FHIR (HL7® FHIR® Standard). Voir le répertoire des versions publiées
| URL officielle: https://interop.esante.gouv.fr/ig/cda/fr-patient-summary/StructureDefinition/fr-cda-clinical-document-ips | Version: 0.1.0 | ||||
| Draft à date du 2026-10-22 | Nom computable: FRCDAClinicalDocumentIPS | ||||
L'élément de l'en-tête CDA 'ClinicalDocument' est l’élément racine d’un document médical IPS (International Patient Summary).
Utilisations:
Vous pouvez également vérifier les usages dans le FHIR IG Statistics
Description des profils, des différentiels, des instantanés et de leurs représentations.
Cette structure est dérivée de FRCDAClinicalDocument
| Nom | Drapeaux | Card. | Type | Description et contraintes Filter: ![]() |
|---|---|---|---|---|
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1..1 | FRCDAClinicalDocument(0.1.0) | Espace de noms (namespace) XML: urn:hl7-org:v3 Base for all types and resources Les instances de ce type sont validées par templateId Conteneur logique: ClinicalDocument (CDA Class) | |
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4..* | II | Déclarations de conformité. Slice: Non ordonné, Ouvert par 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) | Motif requis: 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) | Motif requis: 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) | Motif requis: 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) | Motif requis: 1.2.250.1.213.1.1.1.51 (extensions allowed) | |
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0..1 | st(2.0.3-sd) | Motif requis: 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) | Motif requis: 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) | Motif requis: 2.16.840.1.113883.6.1 (extensions allowed) | |
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0..1 | st(2.0.3-sd) | Motif requis: LOINC (extensions allowed) | |
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0..1 | st(2.0.3-sd) | Motif requis: 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: Non ordonné, Ouvert par 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 Motif requis: 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) Motif requis: PCP (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: CORRE (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: 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) | Motif requis: 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 Motif requis: 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) Motif requis: 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) | Motif requis: 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 Motif requis: 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) Motif requis: 353 (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: CORRE (extensions allowed) | |
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1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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: Non ordonné, Ouvert par 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: Non ordonné, Ouvert par 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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Contenu/Règles pour toutes les 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 pour ce format | ||||
| Id | Grade | Chemin(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)
|
| Chemin | Statut | Usage | Jeu de valeurs (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 | Std. FHIR |
| 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 | Std. FHIR |
| 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 | Std. FHIR |
| 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 | Std. FHIR |
| 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 | Chemin(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)
|
Cette structure est dérivée de FRCDAClinicalDocument
Résumé
Obligatoire : 8 éléments(5 éléments obligatoire(s) imbriqué(s))
Structures
Cette structure fait référence à ces autres structures:
Slices
Cette structure définit les slices suivantes:
Vue différentielle
Cette structure est dérivée de FRCDAClinicalDocument
| Nom | Drapeaux | Card. | Type | Description et contraintes Filter: ![]() |
|---|---|---|---|---|
![]() |
1..1 | FRCDAClinicalDocument(0.1.0) | Espace de noms (namespace) XML: urn:hl7-org:v3 Base for all types and resources Les instances de ce type sont validées par templateId Conteneur logique: ClinicalDocument (CDA Class) | |
![]() ![]() |
4..* | II | Déclarations de conformité. Slice: Non ordonné, Ouvert par 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) | Motif requis: 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) | Motif requis: 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) | Motif requis: 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) | Motif requis: 1.2.250.1.213.1.1.1.51 (extensions allowed) | |
![]() ![]() ![]() ![]() |
0..1 | st(2.0.3-sd) | Motif requis: 2024.01 (extensions allowed) | |
![]() ![]() |
1..1 | CE | Type de document : Synthèse Médicale (code LOINC 60591-5). | |
![]() ![]() ![]() |
0..1 | cs(2.0.3-sd) | Motif requis: 60591-5 (extensions allowed) | |
![]() ![]() ![]() |
0..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 2.16.840.1.113883.6.1 (extensions allowed) | |
![]() ![]() ![]() |
0..1 | st(2.0.3-sd) | Motif requis: LOINC (extensions allowed) | |
![]() ![]() ![]() |
0..1 | st(2.0.3-sd) | Motif requis: 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: Non ordonné, Ouvert par 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 Motif requis: 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) Motif requis: PCP (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: CORRE (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: ES-PREF (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: ES-REF (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: 353 (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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 Motif requis: 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) Motif requis: CORRE (extensions allowed) | |
![]() ![]() ![]() ![]() ![]() |
1..1 | oid(2.0.3-sd), uuid(2.0.3-sd), ruid(2.0.3-sd) | Motif requis: 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: Non ordonné, Ouvert par 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) | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation Slice: Non ordonné, Ouvert par 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 | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
Contenu/Règles pour toutes les slices | |||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | FRCDAGroupeEvaluationEtatPsychiqueDLU(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | FRCDAGroupeEvaluationHandicapsDLU(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | FRCDAGroupeEvaluationDeplacementsDLU(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | FRCDAGroupeEvaluationAutresRisquesDLU(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..2 | Entry | Entrée FR-Groupe-de-questionnaires-d-evaluation | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | FRCDAGroupeEvaluationScoreDLU(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionSignesVitaux(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionHabitusModeDeVie(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionAntecedentsFamiliaux(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionFacteursDeRisqueProfessionnelsNonCode(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionVaccinations(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionHistoriqueDesGrossesses(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionPlanDeSoins(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionDirectivesAnticipees(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionResultats(0.1.0) | ||
![]() ![]() ![]() ![]() ![]() |
0..1 | InfrastructureRoot | ||
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | FRCDASectionDocumentsAjoutes(0.1.0) | ||
Documentation pour ce format | ||||
| Id | Grade | Chemin(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)
|
Vue d'ensembleView
| Chemin | Statut | Usage | Jeu de valeurs (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 | Std. FHIR |
| 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 | Std. FHIR |
| 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 | Std. FHIR |
| 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 | Std. FHIR |
| 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 | Chemin(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)
|
Cette structure est dérivée de FRCDAClinicalDocument
Résumé
Obligatoire : 8 éléments(5 éléments obligatoire(s) imbriqué(s))
Structures
Cette structure fait référence à ces autres structures:
Slices
Cette structure définit les slices suivantes: