Child Screening
Domain Message Specification

NewBornPhysicalExamination Tabular View

COCD_TP146004GB02
NewBornPhysicalExamination

This template class constrains the CDA Procedure class.

This class represents physical examinations of a newborn or infant.

The type of examination and results are carried in a component Examination class

Used by:
[1..1] [M] classCode (CS { CNE: ActClass } )
{ Fixed="PROC" }

Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as procedure.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "PROC".
[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as procedure event.

Implementation in XML Instance

  • The XML attribute moodCode is fixed to "EVN".
[1..1] [M] code (CV { CNE:SnomedCT } )
{ Fixed="243788004" }

Model Attribute Description

The HL7 attribute code uses a code from SNOMED CT to describe this as a child examination.

Implementation in XML Instance

The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows:

  • The XML attribute code shall contain the fixed value "243788004".
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15".
  • The XML attribute displayName shall carry the description associated with the code. It is recommended that the preferred term is used to populate this attribute.
[1..1] [M] effectiveTime (TS)

Model Attribute Description

The HL7 attribute effectiveTime is used to indicate when the newborn physical examination was done.

Implementation in XML Instance

The XML attribute value of the XML element effectiveTime shall be populated with the time that the newborn physical examination was done using a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where:

  • yyyy is the year
  • mm is the month
  • dd is the day
  • hh is the hour
  • mm is the minutes
  • ss is the seconds
  • [+|-ZZzz] is the time zone offset in hours and minutes

Sections from the right of this representation may be left off when the sending system does not record to this level of accuracy. When hours are present, the time zone offset must also be present.

[1..1] [M] id (II)

Model Attribute Description

The HL7 attribute id uses an identifier to identify each instance of a newborn physical examination.

Implementation in XML Instance

The Identifier Global data type flavour is used to carry this information in the XML element id as follows:

  • The XML attribute root shall contain a DCE UUID.
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146004GB02#NewBornPhysicalExamination" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146004GB02#NewBornPhysicalExamination"
[0..1] author

This template class constrains the CDA author class.

The author of this information must be included if the author is different to the document (inherited) author.

If there is no known author for the information held on the source system then:

  • The information may be included and the document author will be deemed to be the author (by inheritance). The author should be asked to decide whether this is acceptable of not.
  • If the document author does not want to be considered as the author of the information then information must not be included in the document.

[1..1] [M] typeCode (CS { CNE: ParticipationType } )
{ Fixed="AUT" }

Model Attribute Description

The HL7 attribute typeCode describes this class as an author participation.

Implementation in XML Instance

  • The XML attribute typeCode is fixed to "AUT".
[1..1] [M] contextControlCode (CS { CNE: ContextControl } )
{ Fixed="OP" }

Model Attribute Description

The HL7 attribute contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent class are conducted across to the child class (also associated with the child class). This set of codes also determine how these participations conduct.

The conduction can only take place if the contextConductionInd in the actRelationships is set to "true".

The value of this attribute is fixed in the HL7 model to "OP":

  • "O" (Overriding) - the author replaces any author that has been conducted from any previous acts.
  • "P" (Propagating) - the author is conducted to all child acts where the contextConductionInd is set to "true".

Implementation in XML Instance

  • The XML attribute contextControlCode shall contain the value "OP"
[1..1] [M] contentId (II) { "NPFIT-000196#Role" }

Model Attribute Description

The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at runtime with a value from the allowed list contained in the model.


Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element contentId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] functionCode (CV { CNE:AuthorFunctionType } )
{ Fixed="OA" }

Model Attribute Description

The HL7 attribute functionCode uses a code from the vocabulary AuthorFunctionType to describe the function of the author

Implementation in XML Instance

The Coded Plain data type flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element functionCode as follows:

  • The XML attribute code is fixed to "OA"
  • The XML attribute codeSystem is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.17.178"
  • The XML attribute displayName is fixed to the author's function name "Originating Author".
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146004GB02#author" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146004GB02#author"
[1..1] [R] time (TS)

Model Attribute Description

The HL7 attribute time is used to define the time the author originally recorded the newborn examination.

Implementation in XML Instance

The XML attribute value of the XML element time shall be populated with the time that author recorded the information using a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where:

  • yyyy is the year
  • mm is the month
  • dd is the day
  • hh is the hour
  • mm is the minutes
  • ss is the seconds
  • [+|-ZZzz] is the time zone offset in hours and minutes

Sections from the right of this representation may be left off when the sending system does not record to this level of accuracy. When hours are present, the time zone offset must also be present.

Where no time is recorded or available then:

  • The XML attribute nullFlavor of the XML element time shall contain the value "UNK"
[1..1] participant (AuthorChoice)

A link to the choice of authors.

[0..1] entryRelationship

This template class constrains the CDA entryRelationship entry class.

This class is a component class used to link to the gestational age class.

[1..1] [M] typeCode (CS { CNE: ActRelationshipType } )
{ Fixed="COMP" }

Model Attribute Description

The HL7 attribute typeCode uses a code to describe this class as a component.

Implementation in XML Instance

  • The XML attribute typeCode is fixed to "COMP".
[1..1] [M] contextConductionInd (BL)
{ Fixed="true" }

Model Attribute Description

The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent class is conducted across to the child class (also associated with the child class).

Implementation in XML Instance

  • The XML attribute contextConductionInd is fixed to "true".
[1..1] [M] seperatableInd (BL)
{ Fixed="false" }

Model Attribute Description

The HL7 attribute seperatableInd uses a Boolean (true or false) to indicate whether two pieces of information can be interpreted separately.

Implementation in XML Instance

  • The XML attribute seperatableInd is fixed to "false".
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146004GB02#entryRelationship" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146004GB02#entryRelationship"
[1..1] gestationalAge (GestationalAge)

A link to the gestational age.

[0..*] entryRelationship1

This template class constrains the CDA entryRelationship class.

This class is a component class, it is used to link to the NewBornPhysicalExamination class, to the Examination class.

[1..1] [M] typeCode (CS { CNE: ActRelationshipType } )
{ Fixed="COMP" }

Model Attribute Description

The HL7 attribute typeCode uses a code to describe this class as a component.

Implementation in XML Instance

  • The XML attribute typeCode is fixed to "COMP".
[1..1] [M] contextConductionInd (BL)
{ Fixed="true" }

Model Attribute Description

The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent class is conducted across to the child class (also associated with the child class).

Implementation in XML Instance

  • The XML attribute contextConductionInd is fixed to "true".
[1..1] [M] seperatableInd (BL)
{ Fixed="false" }

Model Attribute Description

The HL7 attribute seperatableInd uses a Boolean (true or false) to indicate whether two pieces of information can be interpreted separately.

Implementation in XML Instance

  • The XML attribute seperatableInd is fixed to "false".
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146004GB02#entryRelationship1" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146004GB02#entryRelationship1"
[1..1] examination (Examination)
A link to the examination class.
GestationalAge

This template class constrains the CDA observation entry class.

This class represents the gestational age of the newborn or infant.
Used by: NewBornPhysicalExamination
[1..1] [M] classCode (CS { CNE: ActClass } )
{ Fixed="OBS" }

Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as an observation.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "OBS".
[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as an observation event.

Implementation in XML Instance

  • The XML attribute moodCode is fixed to "EVN".
[1..1] [M] code (CV { CNE:CDAObservationType } )
{ Fixed="GA" }

Model Attribute Description

The HL7 attribute code uses a code from the CDAObservationType vocabulary to describe this class gestational age observation.

The Coded Value (CV) data type shall be used to carry this information in the XML element code as follows:

  • The XML attribute code shall contain the fixed value "GA"
  • The XML attribute codeSystem shall contain the fixed value "2.16.840.1.113883.2.1.3.2.4.17.220"
  • The XML attribute displayName shall contain the fixed value "Gestational age".
    .
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146004GB02#gestationalAge" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146004GB02#gestationalAge"
[1..1] [M] value (PQ)

Model Attribute Description

The HL7 attribute value is used to carry the gestational age of the newborn or infant in whole weeks.

Implementation in XML Instance

The XML element value should be populated using the PQ data type as follows:
  • The XML attribute xsi:type shall contain the value "PQ".
  • The XML attribute unit shall contain the value "w".
  • The XML attribute value shall contain the number of weeks as an integer.
AuthorChoice
A choice of author templates.
Used by: NewBornPhysicalExamination
[1..1] : Template1
An abstract placeholder for templates of authors.
Examination

This template class constrains the CDA observation entry class.

This class represents the actual examination detail and the result of that examination.
Used by: NewBornPhysicalExamination
[1..1] [M] classCode (CS { CNE: ActClass } )
{ Fixed="OBS" }

Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as an observation.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "OBS".
[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as an observation event.

Implementation in XML Instance

  • The XML attribute moodCode is fixed to "EVN".
[1..1] [M] code (CV { CNE:NewbornAndInfantPhysicalExaminationProceduresSnCT } )

Model Attribute Description

The HL7 attribute code uses a code from the NewbornAndInfantPhysicalExaminationProceduresSnCT vocabulary to describe the type of examination procedure, the result of which is carried in the HL7 attribute value of this class.

Implementation in XML Instance

The Coded Plain data type flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element code as follows:

  • The XML attribute code shall contain a value from the "NewbornAndInfantPhysicalExaminationProceduresSnCT" vocabulary.
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15".
  • The XML attribute displayName shall carry a description associated with the code in the subset stated in the "NewbornAndInfantPhysicalExaminationProceduresSnCT" vocabulary. It is recommended that the preferred term is used to populate this attribute.
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146004GB02#examination" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the classname within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2".
  • The XML attribute extension is fixed to "COCD_TP146004GB02#examination".
[1..1] [M] value (CD { CWE:NewbornAndInfantPhysicalExaminationResults } )

Model Attribute Description

The HL7 attribute value uses a code from the NewbornAndInfantPhysicalExaminationResults vocabulary to describe the Newborn and Infant Physical Examination Result, this value is the result of the procedure described in the HL7 attribute code of this class. This attribute is specified as CWE and therefore other vocabularies may be used where there is a business need to do so.

Implementation in XML Instance

When using the NewbornAndInfantPhysicalExaminationResults vocabulary coded values then:

The Coded Translated data type flavour of the Concept Descriptor (CD) data type shall be used to carry this information in the XML element value as follows:

  • The XML attribute code shall contain a value from the "NewbornAndInfantPhysicalExaminationResults" vocabulary.
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.17.525".
  • The XML attribute displayName shall carry the description associated with the code stated in the NewbornAndInfantPhysicalExaminationResults vocabulary.
  • The XML element translation may be populated as follows to support translation to an alternate coding system representation of the same information.
    • When translating to the Version 2 of the Read Codes (commonly known as READ2):
      • The XML attribute code shall contain the value from the READ2 coding scheme.
      • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.6.2".
      • The XML attribute displayName may carry the description associated with the code.
    • When translating to the Version 3 of the Read Codes (commonly known as Clinical Terms Version 3,CTV3):
      • The XML attribute code shall contain the value from the CTV3 coding scheme.
      • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.14".
      • The XML attribute displayName may carry the description associated with the code.
    • When translating to the SNOMED CT concepts
      • The XML attribute code shall contain the value from the Newborn and infant physical examination outcomes subset with subset original id 63661000000137.
      • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15".
      • The XML attribute displayName shall carry the description associated with the concept stated in the Newborn and infant physical examination outcomes subset. It is recommended that the preferred term is used to populate this attribute
    • When translating to other coding systems (schemes):
      • The XML attribute code shall contain the value from the that coding scheme.
      • The XML attribute codeSystem shall contain the OID for that coding scheme.
      • The XML attribute displayName may carry the description associated with the code.