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Packagehl7.fhir.cz.korder
Resource TypeStructureDefinition
IdStructureDefinition-LMEnClinicalInformationCz.json
FHIR VersionR4
Sourcehttps://build.fhir.org/ig/HL7-cz/k-order/StructureDefinition-LMEnClinicalInformationCz.html
URLhttps://hl7.cz/fhir/korder/StructureDefinition/LMEnClinicalInformationCz
Version0.0.3
Statusdraft
Date2026-04-02T06:29:39+00:00
NameLMEnOrderClinicalInformationCz
TitleA.3.1 - Clinical Information (Medical History)
Realmcz
Authorityhl7
DescriptionInformation and data communicated to the performing site that may affect execution of the order or interpretation of the results.
Typehttps://hl7.cz/fhir/korder/StructureDefinition/LMEnClinicalInformationCz
Kindlogical

Resources that use this resource

StructureDefinition
hl7.fhir.cz.korder#currentLMEnBodyFTOrderA.2 - Document Body
hl7.fhir.cz.korder#currentLMEnBodyKOrderA.2 A.3“ Document Body

Resources that this resource uses

No resources found


Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: StructureDefinition LMEnClinicalInformationCz

NameFlagsCard.TypeDescription & Constraintsdoco
.. LMEnClinicalInformationCz 0..*BaseA.3.1 - Clinical Information (Medical History)
... clinicalInformationText 0..1stringA.3.1.1 - Clinical information in free text
... clinicalInformationCode 0..1CodeableConceptA.3.1.2 - Clinical information (medical history), formalized
... description 0..*CodeableConceptA.3.1.3 - Description of problem / diagnosis / condition
... medication 0..*BaseA.3.1.4 - Medication
.... id 0..*IdentifierA.3.1.4.1 - Medication ID
.... code 0..*codeA.3.1.4.2 - Medication code
.... quantity 0..1RatioA.3.1.4.3 - Quantity
... vaccination 0..*CodeableConceptA.3.1.5 - Vaccination
... finding 0..*CodeableConceptA.3.1.6 - Physical finding
... hospitalizationDate 0..*dateTimeA.3.1.7 - Date
... urgentInformation 0..1BaseA.3.1.8 - Urgent information
.... allergies 1..*CodeableConceptA.3.1.8.1 - Allergies and intolerances
.... warnings 0..*stringA.3.1.8.2 - Warnings
... additionalData 0..1BaseA.3.1.9 - Additional formalized data
.... date 0..1dateTimeA.3.1.9.1 - Date
.... code 1..1CodeableConceptA.3.1.9.2 - Code
.... value 0..1NarrativeA.3.1.9.3 - Value
This profile does not constrain the narrative in regard to content, language, or traceability to data elements

doco Documentation for this format

Source1

{
  "resourceType": "StructureDefinition",
  "id": "LMEnClinicalInformationCz",
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger": 1
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode": "draft"
    }
  ],
  "url": "https://hl7.cz/fhir/korder/StructureDefinition/LMEnClinicalInformationCz",
  "version": "0.0.3",
  "name": "LMEnOrderClinicalInformationCz",
  "title": "A.3.1 - Clinical Information (Medical History)",
  "status": "draft",
  "date": "2026-04-02T06:29:39+00:00",
  "publisher": "HL7 Czech Republic",
  "contact": [
    {
      "name": "HL7 Czech Republic",
      "telecom": [
        {
          "system": "url",
          "value": "https://www.hl7.cz/"
        }
      ]
    }
  ],
  "description": "Information and data communicated to the performing site that may affect execution of the order or interpretation of the results.",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "urn:iso:std:iso:3166",
          "code": "CZ",
          "display": "Czechia"
        }
      ]
    }
  ],
  "fhirVersion": "4.0.1",
  "kind": "logical",
  "abstract": false,
  "type": "https://hl7.cz/fhir/korder/StructureDefinition/LMEnClinicalInformationCz",
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Base",
  "derivation": "specialization",
  "snapshot": {
    "extension": [
      {
        "url": "http://hl7.org/fhir/tools/StructureDefinition/snapshot-base-version",
        "valueString": "4.0.1"
      }
    ],
    "element": [
      {
        "id": "LMEnClinicalInformationCz",
        "path": "LMEnClinicalInformationCz",
        "short": "A.3.1 - Clinical Information (Medical History)",
        "definition": "Information and data communicated to the performing site that may affect execution of the order or interpretation of the results.",
        "min": 0,
        "max": "*",
        "base": {
          "path": "Base",
          "min": 0,
          "max": "*"
        },
        "isModifier": false
      },
      {
        "id": "LMEnClinicalInformationCz.clinicalInformationText",
        "path": "LMEnClinicalInformationCz.clinicalInformationText",
        "short": "A.3.1.1 - Clinical information in free text",
        "definition": "Clinical information necessary for correct execution of the order or interpretation of the results.",
        "min": 0,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.clinicalInformationText",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.clinicalInformationCode",
        "path": "LMEnClinicalInformationCz.clinicalInformationCode",
        "short": "A.3.1.2 - Clinical information (medical history), formalized",
        "definition": "Formalized clinical information (medical history).",
        "min": 0,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.clinicalInformationCode",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.description",
        "path": "LMEnClinicalInformationCz.description",
        "short": "A.3.1.3 - Description of problem / diagnosis / condition",
        "definition": "Diagnoses and other clinical information affecting the course or outcome of the examination.\n- Preferred systems: ICD-10\n- Preferred systems: Orphacode",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.description",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication",
        "path": "LMEnClinicalInformationCz.medication",
        "short": "A.3.1.4 - Medication",
        "definition": "Medication block containing information on medication affecting the course or outcome of the examination or its interpretation.\n- Preferred systems: DLP\n- Preferred systems: ATC",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.medication",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "Base"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication.id",
        "path": "LMEnClinicalInformationCz.medication.id",
        "short": "A.3.1.4.1 - Medication ID",
        "definition": "Medication ID.",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.medication.id",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "Identifier"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication.code",
        "path": "LMEnClinicalInformationCz.medication.code",
        "short": "A.3.1.4.2 - Medication code",
        "definition": "Medication code.",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.medication.code",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "code"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication.quantity",
        "path": "LMEnClinicalInformationCz.medication.quantity",
        "short": "A.3.1.4.3 - Quantity",
        "definition": "Medication quantity.",
        "min": 0,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.medication.quantity",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "Ratio"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.vaccination",
        "path": "LMEnClinicalInformationCz.vaccination",
        "short": "A.3.1.5 - Vaccination",
        "definition": "Vaccination.",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.vaccination",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.finding",
        "path": "LMEnClinicalInformationCz.finding",
        "short": "A.3.1.6 - Physical finding",
        "definition": "Physical examination of the patient (systolic and diastolic blood pressure, heart rate, oxygen saturation, respiratory rate, current body temperature).",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.finding",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.hospitalizationDate",
        "path": "LMEnClinicalInformationCz.hospitalizationDate",
        "short": "A.3.1.7 - Date",
        "definition": "Date of patient hospitalization.",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.hospitalizationDate",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "dateTime"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.urgentInformation",
        "path": "LMEnClinicalInformationCz.urgentInformation",
        "short": "A.3.1.8 - Urgent information",
        "definition": "Urgent information block in the same structure as in other document types (discharge report, patient summary).",
        "min": 0,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.urgentInformation",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "Base"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.urgentInformation.allergies",
        "path": "LMEnClinicalInformationCz.urgentInformation.allergies",
        "short": "A.3.1.8.1 - Allergies and intolerances",
        "definition": "Allergies and intolerances that may affect execution of the order or interpretation of the results.",
        "min": 1,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.urgentInformation.allergies",
          "min": 1,
          "max": "*"
        },
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.urgentInformation.warnings",
        "path": "LMEnClinicalInformationCz.urgentInformation.warnings",
        "short": "A.3.1.8.2 - Warnings",
        "definition": "Warnings and alerts that may affect execution of the order or interpretation of the results.",
        "min": 0,
        "max": "*",
        "base": {
          "path": "LMEnClinicalInformationCz.urgentInformation.warnings",
          "min": 0,
          "max": "*"
        },
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData",
        "path": "LMEnClinicalInformationCz.additionalData",
        "short": "A.3.1.9 - Additional formalized data",
        "definition": "A.3.1.9 - Additional formalized data",
        "min": 0,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.additionalData",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "Base"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData.date",
        "path": "LMEnClinicalInformationCz.additionalData.date",
        "short": "A.3.1.9.1 - Date",
        "definition": "Date when the data was determined; provided if different from the order issue date.",
        "min": 0,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.additionalData.date",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "dateTime"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData.code",
        "path": "LMEnClinicalInformationCz.additionalData.code",
        "short": "A.3.1.9.2 - Code",
        "definition": "Observation code identifying the meaning of the data item (height, weight, week of pregnancy, etc.).\n- Preferred systems: NCLP\n- Preferred systems: SNOMED CT",
        "min": 1,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.additionalData.code",
          "min": 1,
          "max": "1"
        },
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData.value",
        "path": "LMEnClinicalInformationCz.additionalData.value",
        "short": "A.3.1.9.3 - Value",
        "definition": "Value of the data item including measurement unit.",
        "min": 0,
        "max": "1",
        "base": {
          "path": "LMEnClinicalInformationCz.additionalData.value",
          "min": 0,
          "max": "1"
        },
        "type": [
          {
            "code": "Narrative"
          }
        ]
      }
    ]
  },
  "differential": {
    "element": [
      {
        "id": "LMEnClinicalInformationCz",
        "path": "LMEnClinicalInformationCz",
        "short": "A.3.1 - Clinical Information (Medical History)",
        "definition": "Information and data communicated to the performing site that may affect execution of the order or interpretation of the results."
      },
      {
        "id": "LMEnClinicalInformationCz.clinicalInformationText",
        "path": "LMEnClinicalInformationCz.clinicalInformationText",
        "short": "A.3.1.1 - Clinical information in free text",
        "definition": "Clinical information necessary for correct execution of the order or interpretation of the results.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.clinicalInformationCode",
        "path": "LMEnClinicalInformationCz.clinicalInformationCode",
        "short": "A.3.1.2 - Clinical information (medical history), formalized",
        "definition": "Formalized clinical information (medical history).",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.description",
        "path": "LMEnClinicalInformationCz.description",
        "short": "A.3.1.3 - Description of problem / diagnosis / condition",
        "definition": "Diagnoses and other clinical information affecting the course or outcome of the examination.\n- Preferred systems: ICD-10\n- Preferred systems: Orphacode",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication",
        "path": "LMEnClinicalInformationCz.medication",
        "short": "A.3.1.4 - Medication",
        "definition": "Medication block containing information on medication affecting the course or outcome of the examination or its interpretation.\n- Preferred systems: DLP\n- Preferred systems: ATC",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Base"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication.id",
        "path": "LMEnClinicalInformationCz.medication.id",
        "short": "A.3.1.4.1 - Medication ID",
        "definition": "Medication ID.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Identifier"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication.code",
        "path": "LMEnClinicalInformationCz.medication.code",
        "short": "A.3.1.4.2 - Medication code",
        "definition": "Medication code.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "code"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.medication.quantity",
        "path": "LMEnClinicalInformationCz.medication.quantity",
        "short": "A.3.1.4.3 - Quantity",
        "definition": "Medication quantity.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Ratio"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.vaccination",
        "path": "LMEnClinicalInformationCz.vaccination",
        "short": "A.3.1.5 - Vaccination",
        "definition": "Vaccination.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.finding",
        "path": "LMEnClinicalInformationCz.finding",
        "short": "A.3.1.6 - Physical finding",
        "definition": "Physical examination of the patient (systolic and diastolic blood pressure, heart rate, oxygen saturation, respiratory rate, current body temperature).",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.hospitalizationDate",
        "path": "LMEnClinicalInformationCz.hospitalizationDate",
        "short": "A.3.1.7 - Date",
        "definition": "Date of patient hospitalization.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "dateTime"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.urgentInformation",
        "path": "LMEnClinicalInformationCz.urgentInformation",
        "short": "A.3.1.8 - Urgent information",
        "definition": "Urgent information block in the same structure as in other document types (discharge report, patient summary).",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Base"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.urgentInformation.allergies",
        "path": "LMEnClinicalInformationCz.urgentInformation.allergies",
        "short": "A.3.1.8.1 - Allergies and intolerances",
        "definition": "Allergies and intolerances that may affect execution of the order or interpretation of the results.",
        "min": 1,
        "max": "*",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.urgentInformation.warnings",
        "path": "LMEnClinicalInformationCz.urgentInformation.warnings",
        "short": "A.3.1.8.2 - Warnings",
        "definition": "Warnings and alerts that may affect execution of the order or interpretation of the results.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData",
        "path": "LMEnClinicalInformationCz.additionalData",
        "short": "A.3.1.9 - Additional formalized data",
        "definition": "A.3.1.9 - Additional formalized data",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Base"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData.date",
        "path": "LMEnClinicalInformationCz.additionalData.date",
        "short": "A.3.1.9.1 - Date",
        "definition": "Date when the data was determined; provided if different from the order issue date.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "dateTime"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData.code",
        "path": "LMEnClinicalInformationCz.additionalData.code",
        "short": "A.3.1.9.2 - Code",
        "definition": "Observation code identifying the meaning of the data item (height, weight, week of pregnancy, etc.).\n- Preferred systems: NCLP\n- Preferred systems: SNOMED CT",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "LMEnClinicalInformationCz.additionalData.value",
        "path": "LMEnClinicalInformationCz.additionalData.value",
        "short": "A.3.1.9.3 - Value",
        "definition": "Value of the data item including measurement unit.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Narrative"
          }
        ]
      }
    ]
  }
}