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Family_History_Normal.xml
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Family_History_Normal.xml
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<section>
<!-- C-CDAR2 Example Family History Section -->
<templateId root="2.16.840.1.113883.10.20.22.2.15" extension="2014-06-09"/>
<code code="10157-6" codeSystem="2.16.840.1.113883.6.1" displayName="Family History"/>
<title>Family History</title>
<text>
<!-- Narrative may be structured in any manner, but clear references between the narrative and discrete entries are encouraged -->
<table>
<thead>
<tr>
<th>Family Member</th>
<th>Relation</th>
<th>Problem</th>
<th>Age of Onset</th>
<th>Comments</th>
</tr>
</thead>
<tbody>
<tr>
<td rowspan="2">Lucas Valieri</td>
<td ID="FH1rel" rowspan="2">Dad</td>
<td ID="FH1prob1">Stroke</td>
<td ID="FH1prob1age">72</td>
<td ID="FH1prob1comment">Cause of death, January 2003</td>
</tr>
<tr>
<td ID="FH1prob2">High Blood Pressure</td>
<td/>
<td/>
</tr>
<tr>
<td>Mia Jones</td>
<td ID="FH2rel">Mom</td>
<td ID="FH2prob">No known problems</td>
<td/>
<td/>
</tr>
</tbody>
</table>
</text>
<!-- Father died of a stroke -->
<entry>
<!-- Organizes the Father's medical history -->
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2014-06-09"/>
<!-- Unique identifier for this family member's HISTORY (not the individual) -->
<id root="01faa204-db62-4610-864f-cb50b650d0fa" />
<statusCode code="completed"/>
<subject>
<relatedSubject classCode="PRS">
<!-- Identifies subject's relationship to recordTarget (i.e. Patient) -->
<code code="FTH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="Father">
<originalText>
<reference value="#FH1rel"/>
</originalText>
</code>
<subject>
<!-- Unique ID for the father as an individual -->
<sdtc:id extension="98765432-1" root="1.3.6.1.4.1.16517.1" xmlns:sdtc="urn:hl7-org:sdtc" />
<!-- Father's name; could be sent formatted or as a string like this -->
<name>Lucas Valieri</name>
<administrativeGenderCode code="M" />
<!-- Father's birth date/time, SHOULD be sent. In this example, we did not know the
father's birth date, so we assert that the birthTime is "Unknown" -->
<birthTime nullFlavor="UNK" />
<!-- Identifies the father's living status as deceased. -->
<sdtc:deceasedInd value="true" xmlns:sdtc="urn:hl7-org:sdtc" />
<!-- Date and optional time of death (only needed if deceasedInd="true") -->
<sdtc:deceasedTime value="200301" />
</subject>
</relatedSubject>
</subject>
<!-- Stroke observation -->
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2014-06-09"/>
<!-- Unique ID for this individual observation -->
<id root="02faa204-db62-4610-864f-cb50b650d0fa" />
<code code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
<statusCode code="completed"/>
<!-- Date of the stroke -->
<effectiveTime value="200301" />
<!-- The actual finding on the father.
Note: this is deliberately NOT set to 275104002-Family History of Stroke,
since we are saying the father had a "stroke" not a "family history of stroke".
Family History of Stroke would be a valid code to add to the recordTarget's problem list.-->
<value xsi:type="CD" code="230690007" codeSystem="2.16.840.1.113883.6.96" displayName="Stroke">
<originalText>
<reference value="#FH1prob1"/>
</originalText>
</value>
<!-- Age at the time of the event -->
<entryRelationship typeCode="SUBJ" inversionInd="true">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.31"/>
<code code="445518008" displayName="Age at Onset" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
<text>
<reference value="#FH1prob1age"/>
</text>
<statusCode code="completed"/>
<!-- 'a' is UCUM for Years -->
<value xsi:type="PQ" unit="a" value="72"/>
</observation>
</entryRelationship>
<!-- This finding was the cause of death -->
<entryRelationship typeCode="CAUS">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.47"/>
<code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4" />
<text>
<reference value="#FH1prob1comment"/>
</text>
<statusCode code="completed"/>
<value xsi:type="CD" code="419099009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Dead"/>
</observation>
</entryRelationship>
</observation>
</component>
<!-- High Blood Pressure observation -->
<component>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2014-06-09"/>
<!-- Unique ID for this individual observation -->
<id root="04faa204-db62-4610-864f-cb50b650d0fa" />
<code code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
<statusCode code="completed"/>
<!-- Date of blood pressure (unknown) -->
<effectiveTime nullFlavor="UNK" />
<!-- The actual finding on the father.
Again, not using 160357008-Family History of Hypertension, since we're stating
the father HAD hypertension, not a family history of hypertension -->
<value xsi:type="CD" code="59621000" codeSystem="2.16.840.1.113883.6.96" displayName="Essential Hypertension">
<originalText>
<reference value="#FH1prob2"/>
</originalText>
</value>
</observation>
</component>
</organizer>
</entry>
<!-- Mother living with no known problems -->
<entry>
<!-- Organizes the Mother's medical history -->
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.45" extension="2014-06-09"/>
<!-- Unique identifier for this family member's HISTORY (not the individual) -->
<id root="03faa204-db62-4610-864f-cb50b650d0fa" />
<statusCode code="completed"/>
<subject>
<relatedSubject classCode="PRS">
<!-- Identifies subject's relationship to recordTarget (i.e. Patient) -->
<code code="MTH" codeSystem="2.16.840.1.113883.5.111" codeSystemName="HL7 RoleCode" displayName="Mother">
<originalText>
<reference value="#FH2rel"/>
</originalText>
</code>
<subject>
<!-- Unique ID for the mother as an individual
(note - different extension than father) -->
<sdtc:id extension="98765432-2" root="1.3.6.1.4.1.16517.1" xmlns:sdtc="urn:hl7-org:sdtc" />
<!-- Mother's name; could be sent formatted or as a string like this -->
<name>Mia Jones</name>
<administrativeGenderCode code="F" />
<!-- Mother's birth time, SHOULD be sent -->
<birthTime nullFlavor="UNK" />
<!-- Identifies the mother's living status as living. -->
<sdtc:deceasedInd value="false" xmlns:sdtc="urn:hl7-org:sdtc" />
</subject>
</relatedSubject>
</subject>
<component>
<observation classCode="OBS" moodCode="EVN" negationInd="true">
<!-- Similar to no known problems or allergies,
the use of negationInd corresponds with the newer Observation.ValueNegationInd
The negationInd = true negates the value element -->
<templateId root="2.16.840.1.113883.10.20.22.4.46" extension="2014-06-09"/>
<!-- Unique ID for this individual observation -->
<id root="05faa204-db62-4610-864f-cb50b650d0fa" />
<code code="75315-2" codeSystem="2.16.840.1.113883.6.1" displayName="Condition Family Member" />
<text>
<reference value="#FH2prob"/>
</text>
<statusCode code="completed"/>
<effectiveTime nullFlavor="NI" />
<!-- Generic problem; negationInd identifies the mother has having no active problems-->
<value xsi:type="CD" code="55607006" codeSystem="2.16.840.1.113883.6.96" displayName="Problem" />
</observation>
</component>
</organizer>
</entry>
</section>