Section Name & # Data Elements Data Element Descriptions Cardinality Additional Notes Description Name: Metadata 1 See metadata See metadata. Single Name: Applicability 2 See Expression component See Expression component. This Single Unlike the elements in the element describes the clinical metadata, this element can be used conditions in which this within the clinical setting to identify documentation template is templates that are applicable to the applicable patient. 3 Attribute-Value List See Attribute-Value component. Single A list of items which allows for Name: Implementation extensible section metadata, to Extensions support application-specific needs. Description: For storing metadata. Name: 4 Title A descriptive title for the section Single Examples of Sections: History of Documentation present illness, Physical Exam, Section Review of Systems 5 Subsection Subsections of the documentation Multiple GI System Review, Respiratory template System Review Description: The document template is 6 Documentation Concept The clinical concept being Multiple E.g., Blood pressure, History of chest composed of a documented. pain number of sections that organize the 7 Section Cardinality Indicator of whether one or Single concepts multiple instances of this section
Section Name & Description # Data Elements Data Element Descriptions Cardinality Additional Notes Name: Metadata 1 See metadata See metadata. Single Name: Applicability 2 See Expression component See Expression component. This element describes the clinical conditions in which this documentation template is applicable Single Unlike the elements in the metadata, this element can be used within the clinical setting to identify templates that are applicable to the patient. Name: Implementation Extensions Description: For storing metadata. 3 Attribute-Value List See Attribute-Value component. Single A list of items which allows for extensible section metadata, to support application-specific needs. Name: Documentation Section Description: The document template is composed of a number of sections that organize the concepts 4 Title A descriptive title for the section Single Examples of Sections: History of present illness, Physical Exam, Review of Systems 5 Subsection Subsections of the documentation template Multiple GI System Review, Respiratory System Review 6 Documentation Concept The clinical concept being documented. Multiple E.g., Blood pressure, History of chest pain 7 Section Cardinality Indicator of whether one or multiple instances of this section Single
SIFramework_HeD_UC1_CDSArtifactSharing_v1.0.docx