臨床サマリー情報

 

エレメント構造図

 

 

 

エレメント一覧表

 

　

Elements

　

　

　

　

Attribute

Datatypes

Occurrence

Table id

1.

mmlSm:SummaryModule

　

　

　

　

1.1.

 

mmlSm:serviceHistory

 

 

 

　

　

 

 

 

 

 

 

 

 

mmlSm:start

date

#IMPLIED

　

　

 

 

 

 

 

 

 

 

mmlSm:end

date

#IMPLIED

　

1.1.1.

 

 

mmlSm:outPatient

 

 

?

　

1.1.1.1.

 

 

 

mmlSm:outPatientItem

 

 

*

　

1.1.1.1.1.

 

 

 

 

mmlSm:date

 

date

 

　

1.1.1.1.2.

 

 

 

 

mmlSm:outPatientCondition

 

string

?

　

　

 

 

 

 

 

 

 

 

mmlSm:first

boolean

#IMPLIED

　

　

 

 

 

 

 

 

 

 

mmlSm:emergency

boolean

#IMPLIED

　

1.1.1.1.3.

 

 

 

 

mmlSm:staffs

 

 

?

　

1.1.1.1.3.1.

 

 

 

 

 

mmlSm:staffInfo

 

 

+

　

1.1.1.1.3.1.1.

 

 

 

 

 

 

mmlPsi:PersonalizedInfo

 

 

 

　

1.1.1.1.3.1.2.

 

 

 

 

 

 

mmlCi:creatorLicense

 

 

+

　

1.1.2.

 

 

mmlSm:inPatient

 

 

?

　

1.1.2.1.

 

 

 

mmlSm:inPatientItem

 

 

*

　

1.1.2.1.1.

 

 

 

 

mmlSm:admission

 

 

 

　

1.1.2.1.1.1.

 

 

 

 

 

mmlSm:date

 

date

 

　

1.1.2.1.1.2.

 

 

 

 

 

mmlSm:admissionCondition

 

string

?

　

　

 

 

 

 

 

 

 

 

mmlSm:emergency

boolean

#IMPLIED

　

1.1.2.1.1.3.

 

 

 

 

 

mmlSm:referFrom

 

 

?

　

1.1.2.1.1.3.1.

 

 

 

 

 

 

mmlPsi:PersonalizedInfo

 

 

 

　

1.1.2.1.2.

 

 

 

 

mmlSm:discharge

 

 

 

　

1.1.2.1.2.1.

 

 

 

 

 

mmlSm:date

 

date

 

　

1.1.2.1.2.2.

 

 

 

 

 

mmlSm:dischargeCondition

 

string

?

　

　

 

 

 

 

 

 

 

 

mmlSm:outcome

string

#IMPLIED

MML0016

1.1.2.1.2.3.

 

 

 

 

 

mmlSm:referTo

 

 

?

　

1.1.2.1.2.3.1.

 

 

 

 

 

 

mmlPsi:PersonalizedInfo

 

 

 

　

1.1.2.1.3.

 

 

 

 

mmlSm:staffs

 

 

?

　

1.1.2.1.3.1.

 

 

 

 

 

mmlSm:staffInfo

 

 

+

　

1.1.2.1.3.1.1.

 

 

 

 

 

 

mmlPsi:PersonalizedInfo

 

 

 

　

1.1.2.1.3.1.2.

 

 

 

 

 

 

mmlCi:creatorLicense

 

 

+

　

1.2.

 

mmlRd:RegisteredDiagnosisModule

 

 

*

　

1.3.

 

mmlSm:deathInfo

 

 

?

　

　

 

 

 

 

 

 

 

 

mmlSm:date

date/dateTime

#IMPLIED

　

　

 

 

 

 

 

 

 

 

mmlSm:autopsy

boolean

#IMPLIED

　

1.4.

 

mmlSg:SurgeryModule

 

 

*

　

1.5.

 

mmlSm:chiefComplaints

 

string

?

　

1.6.

 

mmlSm:patientProfile

 

string

?

　

1.7.

 

mmlSm:history

 

string

?

　

1.8.

 

mmlSm:physicalExam

 

string

?

　

1.8.1.

 

 

mmlCm:extRef

 

 

*

　

1.9.

 

mmlSm:clinicalCourse

 

 

?

　

1.9.1.

 

 

mmlSm:clinicalRecord

 

string

+

　

　

 

 

 

 

 

 

 

 

mmlSm:date

date/dateTime

#IMPLIED

　

1.9.1.1.

 

 

 

mmlCm:extRef

 

 

*

　

1.9.1.2.

 

 

 

mmlSm:relatedDoc

 

string

*

　

　

 

 

 

 

 

 

 

 

mmlSm:relation

string

#IMPLIED

MML0008

1.10.

 

mmlSm:dischargeFindings

 

string

?

　

1.10.1.

 

 

mmlCm:extRef

 

 

*

　

1.11.

 

mmlSm:medication

 

string

?

　

1.11.1.

 

 

mmlCm:extRef

 

 

*

　

1.12.

 

mmlSm:testResults

 

 

?

　

1.12.1.

 

 

mmlSm:testResult

 

string

+

　

　

 

 

 

 

 

 

 

 

mmlSm:date

date/dateTime

#IMPLIED

　

1.12.1.1.

 

 

 

mmlCm:extRef

 

 

*

　

1.13.

 

mmlSm:plan

 

 

 

string

?

　

1.13.1.

 

 

mmlCm:extRef

 

 

*

　

1.14.

　

mmlSm:remarks

　

string

?

　

Occurrence　　なし：必ず1回出現，?： 0回もしくは1回出現，+： 1回以上出現，*： 0 回以上出現

　　　　　#REQUIRED:必須属性，#IMPLIED:省略可能属性

 

 

運用

臨床サマリー情報は，多くの情報の集合体（臨床経過，患者情報，病名，手術など）である．集合体を構築する方法としては，次のものがある．

構築法１：病名，手術は，外部参照やリンクではなく，mmlSm:SummaryModule内に記載することができる．

構築法2：外部参照やリンクを用いず，mmlSm:SummaryModuleおよび関連モジュール（患者情報，病名，手術など）を，MmlModuleItemの繰り返しにより，一つのMMLインスタンスとしてまとめることができる．この場合，extractPolicy（ＭＭＬ基本構造1.1.4.scopePeriod内にあり）にsummaryと記載し，全体としてサマリー情報であることを明確にしておく．

構築法3：MMLの文書間リンク機能を用いる．すなわち，mmlSm:SummaryModuleを含むMmlModuleItemのparentId（ＭＭＬ基本構造1.2.1.1.3.2.）に，関連モジュールを含むMmlModuleItemのuidを記載する．あるいは，mmlSm:relatedDoc（臨床サマリー情報1.9.mmlSm:clinicalCourse内にあり）に，関連モジュールを含むMmlModuleItemのuidを記載する．一つのMMLインスタンスとしてまとめる必要はない．

いずれの方法も組み合わせて利用可能であり，ユーザーによって選択できる．

 

 

エレメント解説

 

1.mmlSm:SummaryModule

【内容】臨床経過サマリー情報

 

1.1.mmlSm:serviceHistory

【内容】期間情報．本モジュールは，対象を必ずしも一回の入院に限定していない．複数入院，複数外来，および両者の組み合わせを対象とすることもできる．

【省略】不可

【属性】

属性名

データ型

省略

説明

mmlSm:start

date

#IMPLIED

サマリー対象期間の開始日．

mmlSm:end

date

#IMPLIED

サマリー対象期間の終了日．

通常は，start，end（MML基本構造1.2.1.1.4.confirmDateの属性）と同じ値をとる．

【例】

<mmlSm:serviceHistory mmlSm:start = "1999-08-25" mmlSm:end = "1999-08-31">

【例】一年間のサマリー

<mmlSm:serviceHistory mmlSm:start = "1998-01-01" mmlSm:end = "1998-12-31">

 

1.1.1.mmlSm:outPatient

【内容】外来受診歴情報

【省略】省略可

 

1.1.1.1.mmlSm:outPatientItem

【内容】個々の外来受診歴

【省略】省略可

【繰り返し設定】繰り返しあり．外来受診が複数あれば繰り返す．

 

1.1.1.1.1.mmlSm:date

【内容】外来受診日

【データ型】date　書式：CCYY-MM-DD

【省略】不可

【例】8月25日，外来受診

<mmlSm:date>1999-08-25</mmlSm:date>

 

1.1.1.1.2.mmlSm:outPatientCondition

【内容】外来受診状態．

【データ型】string

【省略】省略可

【属性】

属性名

データ型

省略

説明

mmlSm:first

boolean

#IMPLIED

初診．true：初診，false：再診

mmlSm:emergency

boolean

#IMPLIED

救急受診．true：救急，false：通常

【例】初診，緊急受診の場合

<mmlSm:outPatientCondition mmlSm:first = "true" mmlSm:emergency = "true">

        10A.M.the patient was put into the ambulance on a stretcher and driven to our hospital.

</mmlSm:outPatientCondition>

 

1.1.1.1.3.mmlSm:staffs

【内容】患者担当スタッフ情報

【省略】省略可

 

1.1.1.1.3.1.mmlSm:staffInfo

【内容】外来担当スタッフ．

【省略】不可

【繰り返し設定】繰り返しあり．担当スタッフが複数いれば繰り返す．

 

1.1.1.1.3.1.1.mmlPsi:PersonalizedInfo

【内容】個人情報．構造はMML共通形式参照．

【省略】不可

 

1.1.1.1.3.1.2.mmlCi:creatorLicense

【内容】スタッフの資格

【データ型】string

【省略】不可

【繰り返し設定】繰り返しあり．資格が複数ある場合に繰り返す．

 

1.1.2.mmlSm:inPatient

【内容】入院暦情報

【省略】不可

 

1.1.2.1.mmlSm:inPatientItem

【内容】個々の入院暦．繰り返しにより，複数入院，一入院における転棟，転科を記載可能．

【省略】省略可

【繰り返し設定】繰り返しあり．入院が複数あれば繰り返す．

 

1.1.2.1.1.mmlSm:admission

【内容】入院

【省略】不可

 

1.1.2.1.1.1.mmlSm:date

【内容】入院（転入）日

【データ型】date　書式：CCYY-MM-DD

【省略】不可

【例】1999年8月27日，入院

<mmlSm:date>1999-8-27</mmlSm:date>

 

1.1.2.1.1.2.mmlSm:admissionCondition

【内容】入院時状態

【データ型】string

【省略】省略可

【属性】

属性名

データ型

省略

説明

mmlSm:emergency

boolean

#IMPLIED

緊急入院．true：緊急入院，false：通常

【例】救急車にて緊急入院

<mmlSm:admissionCondition mmlSm:emergency = "true">

Emergency admission by ambulance

</mmlSm:admissionCondition>

 

1.1.2.1.1.3.mmlSm:referFrom

【内容】紹介元情報

【省略】省略可

 

1.1.2.1.1.3.1.mmlPsi:PersonalizedInfo

【内容】構造はMML共通形式参照．

【省略】不可

 

【例】新世紀医科大学内科小野洋子医師からの紹介

<mmlSm:referFrom>

        <mmlPsi:PersonalizedInfo>

                <mmlCm:Id mmlCm:type = "facility" mmlCm:tableId = "MML0024">

                        23234567</mmlCm:Id>

                <mmlPsi:personName>

                        <mmlNm:Name mmlNm:repCode = "A" mmlNm:tableId = "MML0025">

                                <mmlNm:family>Ono</mmlNm:family>

                                <mmlNm:given>Yoko</mmlNm:given>

                                <mmlNm:degree>M.D.</mmlNm:degree>

                        </mmlNm:Name>

                </mmlPsi:personName>

                <mmlFc:Facility>

                        <mmlFc:name mmlFc:repCode = "A" mmlFc:tableId = "MML0025">

                                New Millenium Medical College Hospital</mmlFc:name>

                        <mmlCm:Id mmlCm:type = "insurance" mmlCm:tableId = "MML0027">

                                801.006.3</mmlCm:Id>

                </mmlFc:Facility>

                <mmlDp:Department>

                                <mmlDp:name mmlDp:repCode = "A"

                                   mmlDp:tableId = "MML0025"> Internal medicine </mmlDp:name>

                        <mmlCm:Id mmlCm:type = "claim" mmlCm:tableId = "MML0029">01</mmlCm:Id>

                </mmlDp:Department>

        </mmlPsi:PersonalizedInfo>

</mmlSm:referFrom>

 

1.1.2.1.2.mmlSm:discharge

【内容】退院

【省略】不可

 

1.1.2.1.2.1.mmlSm:date

【内容】退院（転出）日

【データ型】date　書式：CCYY-MM-DD

【省略】不可

【例】1999年8月31日，退院

<mmlSm:date>1999-08-31</mmlSm:date>

 

1.1.2.1.2.2.mmlSm:dischargeCondition

【内容】退院時状態

【データ型】string

【省略】省略可

【属性】

属性名

データ型

省略

使用テーブル

説明

mmlSm:outcome

string

#IMPLIED

MML0016

退院時転帰

【例】術後4日目に慢性期病院へ転院

<mmlSm:dischargeCondition mmlSm:outcome = "transferChronic">

        4 P.O.D, the patient was transferred to the chronic hospital.

</mmlSm:dischargeCondition>

 

1.1.2.1.2.3.mmlSm:referTo

【内容】紹介先情報

【省略】不可

 

1.1.2.1.2.3.1.mmlPsi:PersonalizedInfo

【内容】構造はMML共通形式参照．

【省略】不可

【例】新世紀平成病院，循環器科の田中富士子医師へ紹介

<mmlSm:referTo>

        <mmlPsi:PersonalizedInfo>

                <mmlCm:Id mmlCm:type = "facility" mmlCm:tableId = "MML0024">

                        55234567</mmlCm:Id>

        <mmlPsi:personName>

                        <mmlNm:Name mmlNm:repCode = "A" mmlNm:tableId = "MML0025">

                                <mmlNm:family>Tanaka</mmlNm:family>

                                <mmlNm:given>Fujiko</mmlNm:given>

                                <mmlNm:degree>M.D.</mmlNm:degree>

                           </mmlNm:Name>

                   </mmlPsi:personName>

                   <mmlFc:Facility>

                                <mmlFc:name mmlFc:repCode = "A" mmlFc:tableId = "MML0025">

                                        New Millenium Heisei Hospital</mmlFc:name>

                                <mmlCm:Id mmlCm:type = "insurance" mmlCm:tableId = "MML0027">

                                        2354678</mmlCm:Id>

                   </mmlFc:Facility>

                   <mmlDp:Department>

                                <mmlDp:name mmlDp:repCode = "A" mmlDp:tableId = "MML0025">

                                        Cardiology </mmlDp:name>

                                <mmlCm:Id mmlCm:type = "claim" mmlCm:tableId = "MML0029">08</mmlCm:Id>

                   </mmlDp:Department>

           </mmlPsi:PersonalizedInfo>

</mmlSm:referTo>

 

 

1.1.2.1.3.mmlSm:staffs

【内容】患者担当スタッフ情報

【省略】省略可

 

1.1.2.1.3.1.mmlSm:staffInfo

【内容】入院担当スタッフ．

【省略】不可

【繰り返し設定】繰り返しあり．担当スタッフを複数記載する場合に繰り返す．

 

1.1.2.1.3.1.1.mmlPsi:PersonalizedInfo

【内容】構造はMML共通形式参照．

【省略】不可

 

1.1.2.1.3.1.2.mmlCi:creatorLicense

【内容】スタッフの資格

【データ型】string

【省略】不可

【繰り返し設定】繰り返しあり．資格が複数ある場合に繰り返す．

 

【例】入院時の主治医が新世紀医科大学心臓外科の荒木賢二医師の場合

<mmlSm:staffInfo>

        <mmlPsi:PersonalizedInfo>

                <mmlCm:Id mmlCm:type = " facility" mmlCm:tableId = "MML0024">

                        23456789</mmlCm:Id>

                <mmlPsi:personName>

                        <mmlNm:Name mmlNm:repCode = "A" mmlNm:tableId = "MML0025">

                                <mmlNm:family>Araki</mmlNm:family>

                                <mmlNm:given>Kenji</mmlNm:given>

                                <mmlNm:degree>M.D.</mmlNm:degree>

                        </mmlNm:Name>

                </mmlPsi:personName>

                <mmlFc:Facility>

                        <mmlFc:name mmlFc:repCode = "A" mmlFc:tableId = "MML0025">

                                New Millenium Medical College Hospital</mmlFc:name>

                        <mmlCm:Id mmlCm:type = "insurance" mmlCm:tableId = "MML0027">801.006.3</mmlCm:Id>

                </mmlFc:Facility>

                <mmlDp:Department>

                        <mmlDp:name mmlDp:repCode = "A" mmlDp:tableId = "MML0025">

                                Cardiovascular surgery

                        </mmlDp:name>

                        <mmlCm:Id mmlCm:type = " claim" mmlCm:tableId = "MML0029">16</mmlCm:Id>

                </mmlDp:Department>

           </mmlPsi:PersonalizedInfo>

          <mmlCi:creatorLicense mmlCi:tableId = "MML0026">doctor</mmlCi:creatorLicense>

</mmlSm:staffInfo>

 

 

1.2.mmlRd:RegisteredDiagnosisModule

【内容】サマリーにおける診断履歴情報．構造は上記参照．

前述の運用を参照すること．構築法1の場合に，本エレメントを用いる．構築法2および3では，本エレメントは省略される．

【省略】省略可

【繰り返し設定】繰り返しあり．診断名が複数あれば繰り返す．

 

1.3.mmlSm:deathInfo

【内容】死亡関連情報

【データ型】string

【省略】省略可

【属性】

属性名

データ型

省略

説明

mmlSm:date

date/dateTime

#IMPLIED

死亡日時

mmlSm:autopsy

boolean

#IMPLIED

剖検の有無．true：剖検あり，false：なし

【例】1999年8月31，胃癌にて死亡．剖検あり．

<mmlSm:deathInfo mmlSm:date = "1999-08-31" mmlSm:autopsy = "true">

        The patient died of gastric cancer.

</mmlSm:deathInfo>

 

1.4.mmlSg:SurgeryModule

【内容】サマリーにおける手術記録情報．構造は上記参照．

前述の運用を参照すること．構築法1の場合に，本エレメントを用いる．構築法2および3では，本エレメントは省略される．

【省略】省略可

【繰り返し設定】繰り返しあり．複数手術を施行した場合は繰り返す．

 

1.5.mmlSm:chiefComplaints

【内容】主訴

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

【例】

<mmlSm:chiefComplaints>Severe chest pain</mmlSm:chiefComplaints>

 

1.6.mmlSm:patientProfile

【内容】患者プロフィール

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

【例】

<mmlSm:patientProfile>

        The patient is a 40-year-old married forester.

</mmlSm:patientProfile>

 

1.7.mmlSm:history

【内容】入院までの経過．

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

【例】

<mmlSm:history>

On a background of good health, the patient noted the onset of chest pain and dyspnea on Aug 25,1999. At 10 A.M., he was put into the ambulance on a stretcher and driven to our hospital

At arrival, the symptoms subsided and he went home without any medication. Two days ago (Aug 27), he felt intractable chest pain and was referred to the department of cardiovascular surgery under the diagnosis of unstable angina pectoris.

</mmlSm:history>

 

1.8.mmlSm:physicalExam

【内容】入院時理学所見．

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

【例】

<mmlSm:physicalExam>

Physical findings were essentially normal except for the blood pressure which was 160/100. Heart sounds were clear and rhythm was regular without audible murmurs or friction sounds.

</mmlSm:physicalExam>

 

1.8.1.mmlCm:extRef

【内容】構造はMML共通形式（外部参照形式）参照．

【省略】省略可

【繰り返し設定】繰り返しあり．外部参照が複数あれば，数だけ繰り返す．

 

1.9.mmlSm:clinicalCourse

【内容】経過および治療

【省略】省略可

 

1.9.1.mmlSm:clinicalRecord

【内容】経過記録．mmlCm:extRefとmmlSm:relatedDocの混在可能．

【データ型】string

【省略】不可

【繰り返し設定】繰り返しあり．日付や項目にあわせて繰り返す．

【文書のレイアウト】XHTML使用可

【属性】

属性名

データ型

省略

説明

mmlSm:date

date/dateTime

#IMPLIED

イベント発生日時

 

1.9.1.1.mmlCm:extRef

【内容】構造はMML共通形式（外部参照形式）参照．

【省略】省略可

【繰り返し設定】繰り返しあり．外部参照が複数あれば，数だけ繰り返す．

 

1.9.1.2. mmlSm:relatedDoc

【内容】本経過記録に関連するMML文書のMmlModuleItemのuidを記載する．

【データ型】string

【省略】省略可

【繰り返し設定】繰り返しあり．関連文書が複数あれば繰り返す．

【属性】

属性名

データ型

省略

使用テーブル

説明

mmlSm:relatedDoc

string

#IMPLIED

MML0008

関連の種別

 

【例】

<mmlSm:clinicalCourse>

        <mmlSm:clinicalRecord mmlSm:date=”1999-08-27”>

                Emergency coronary angiography was carried out.

                <mmlCm:extRef mmlCm:contentType = "image/jpeg"

                        mmlCm:medicalRole = " angioGraphy "

                        mmlCm:title = "Preoperative coronary angiography"

                        mmlCm:href = "patient001/surgicalFigure003.jpg"/>

                Three vessels (LAD, #9, #12) were involved.

                ＜mmlSm:relatedDoc mmlSm:relation=” detail”＞

                        11D1AC5400A0C94A814796045F768ED5＜/mmlSm:relatedDoc＞

        </mmlSm:clinicalRecord>

</mmlSm:clinicalCourse>

 

1.10.mmlSm:dischargeFindings

【内容】退院時所見．mmlCm:extRefとの混在可能．

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

 

1.10.1.mmlCm:extRef

【内容】構造はMML共通形式（外部参照形式）参照．

【省略】省略可

【繰り返し設定】繰り返しあり．外部参照が複数あれば，数だけ繰り返す．

 

【例】

<mmlSm:dischargeFindings>

        Symptoms free, no wound infection.

</mmlSm:dischargeFindings>

 

1.11.mmlSm:medication

【内容】退院時処方．mmlCm:extRefとの混在可能．

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

 

1.11.1.mmlCm:extRef

【内容】構造はMML共通形式（外部参照形式）参照．

【省略】省略可

【繰り返し設定】繰り返しあり．外部参照が複数あれば，数だけ繰り返す

 

【例】

<mmlSm:medication>

        Prescription on discharge

        <mmlCm:extRef

                mmlCm:contentType = "APPLICATION/HL72.3-HL7ER2.3"

                mmlCm:medicalRole = "prescription"

                mmlCm:title = "Prescription on discharge"

                mmlCm:href = "patient1234/prescription003.HL7"/>

</mmlSm:medication>

 

1.12.mmlSm:testResults

【内容】退院時検査結果．

【省略】省略可

 

1.12.1.mmlSm:testResult

【内容】個々の検査結果．mmlCm:extRefとの混在可能．

【データ型】string

【省略】不可

【繰り返し設定】繰り返しあり．検査が複数あれば繰り返す．

【文書のレイアウト】XHTML使用可

 

1.12.1.1.mmlCm:extRef

【内容】構造はMML共通形式（外部参照形式）参照．

【省略】省略可

【繰り返し設定】繰り返しあり．外部参照が複数あれば，数だけ繰り返す

 

【例】

<mmlSm:testResults>

        <mmlSm:testResult mmlSm:date=” 1999-08-31”>

                Labo findings on discharge

                <mmlCm:extRef

                        mmlCm:contentType = "APPLICATION/HL72.3-HL7ER2.3"

                        mmlCm:medicalRole = " laboratoryTest "

                        mmlCm:title = "Blood chemistry data on discharge"

                        mmlCm:href = "patient1234/prescription004.HL7"/>

        </mmlSm:testResult>

        <mmlSm:testResult mmlSm:date=” 1999-08-31”>

                ECG on discharge. No ST change and new Q wave was observed.

                <mmlCm:extRef

                        mmlCm:contentType = "image/gif"

                        mmlCm:medicalRole = " ecg "

                        mmlCm:title = "ECG on discharge"

                        mmlCm:href = "patient1234/exam004.gif"/>

        </mmlSm:testResult>

</mmlSm:testResults>

 

1.13.mmlSm:plan

【内容】退院後治療方針．mmlCm:extRefとの混在可能．

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

 

1.13.1.mmlCm:extRef

【内容】構造はMML共通形式（外部参照形式）参照．

【省略】省略可

【繰り返し設定】繰り返しあり．外部参照が複数あれば，数だけ繰り返す

 

【例】

<mmlSm:plan>

        Rehabilitation program and wound care will continue in the chronic hospital. .

</mmlSm:plan>

 

1.14.mmlSm:remarks

【内容】患者に関する留意事項

【データ型】string

【省略】省略可

【文書のレイアウト】XHTML使用可

【例】

<mmlSm:remarks>

        Patient education: good. Appointment in outpatient department in 2 weeks.

</mmlSm:remarks>

 

 

 

臨床サマリー情報モジュール　サンプルインスタンス

 

<mmlSm:SummaryModule>

        <mmlSm:serviceHistory mmlSm:start = "1999-08-25" mmlSm:end = "1999-08-31">

                <mmlSm:outPatient>

                        <mmlSm:outPatientItem>

                                <mmlSm:date>1999-08-25</mmlSm:date>

                                <mmlSm:outPatientCondition mmlSm:first = "true" mmlSm:emergency = "true">

                                        10A.M.the patient was put into the ambulance on a stretcher and driven to our hospital.

                                </mmlSm:outPatientCondition>

                                <mmlSm:staffs>

                                        <mmlSm:staffInfo>

                                                <mmlPsi:PersonalizedInfo>

                                                        <mmlCm:Id mmlCm:type = "facility" mmlCm:tableId = "MML0024">

                                                                23234567</mmlCm:Id>

                                                        <mmlPsi:personName>

                                                                <mmlNm:Name mmlNm:repCode = "A"

                                                                        mmlNm:tableId = "MML0025">

                                                                        <mmlNm:family>Ono</mmlNm:family>

                                                                        <mmlNm:given>Yoko</mmlNm:given>

                                                                        <mmlNm:degree>M.D.</mmlNm:degree>

                                                                </mmlNm:Name>

                                                        </mmlPsi:personName>

                                                        <mmlFc:Facility>

                                                                <mmlFc:name mmlFc:repCode = "A"

                                                                        mmlFc:tableId = "MML0025">

                                                                        New Millenium Medical College Hospital </mmlFc:name>

                                                                <mmlCm:Id mmlCm:type = "insurance" mmlCm:tableId = "MML0027">

                                                                        801.006.3</mmlCm:Id>

                                                        </mmlFc:Facility>

                                                        <mmlDp:Department>

                                                                        <mmlDp:name mmlDp:repCode = "A"

                                                                                mmlDp:tableId = "MML0025"> Internal medicine </mmlDp:name>

                                                                <mmlCm:Id mmlCm:type = "claim" mmlCm:tableId = "MML0029">

                                                                        01</mmlCm:Id>

                                                        </mmlDp:Department>

                                                </mmlPsi:PersonalizedInfo>

                                                <mmlCi:creatorLicense mmlCi:tableId = "MML0026">

                                                                doctor </mmlCi:creatorLicense>

                                        </mmlSm:staffInfo>

                                </mmlSm:staffs>

                        </mmlSm:outPatientItem>

                </mmlSm:outPatient>

                <mmlSm:inPatient>

                        <mmlSm:inPatientItem>

                                <mmlSm:admission>

                                        <mmlSm:date>1999-8-27</mmlSm:date>

                                        <mmlSm:admissionCondition mmlSm:emergency = "true">

                                                Emergency admission by ambulance</mmlSm:admissionCondition>

                                        <mmlSm:referFrom>

                                                <mmlPsi:PersonalizedInfo>

                                                        <mmlCm:Id mmlCm:type = "facility" mmlCm:tableId = "MML0024">

                                                                23234567</mmlCm:Id>

                                                        <mmlPsi:personName>

                                                                <mmlNm:Name mmlNm:repCode = "A"

                                                                        mmlNm:tableId = "MML0025">

                                                                        <mmlNm:family>Ono</mmlNm:family>

                                                                        <mmlNm:given>Yoko</mmlNm:given>

                                                                        <mmlNm:degree>M.D.</mmlNm:degree>

                                                                </mmlNm:Name>

                                                        </mmlPsi:personName>

                                                        <mmlFc:Facility>

                                                                <mmlFc:name mmlFc:repCode = "A"

                                                                        mmlFc:tableId = "MML0025">

                                                                        New Millenium Medical College Hospital </mmlFc:name>

                                                                <mmlCm:Id mmlCm:type = "insurance" mmlCm:tableId = "MML0027">

                                                                        801.006.3</mmlCm:Id>

                                                        </mmlFc:Facility>

                                                        <mmlDp:Department>

                                                                        <mmlDp:name mmlDp:repCode = "A"

                                                                                mmlDp:tableId = "MML0025"> Internal medicine </mmlDp:name>

                                                                <mmlCm:Id mmlCm:type = "claim" mmlCm:tableId = "MML0029">

                                                                        01</mmlCm:Id>

                                                        </mmlDp:Department>

                                                </mmlPsi:PersonalizedInfo>

                                        </mmlSm:referFrom>

                                </mmlSm:admission>

                                <mmlSm:discharge>

                                        <mmlSm:date>1999-08-31</mmlSm:date>

                                        <mmlSm:dischargeCondition mmlSm:outcome = "transferChronic">

                                                        4 P.O.D, the patient was transferred to the chronic hospital.

                                        </mmlSm:dischargeCondition>

                                        <mmlSm:referTo>

                                                <mmlPsi:PersonalizedInfo>

                                                        <mmlCm:Id mmlCm:type = "facility" mmlCm:tableId = "MML0024">

                                                                55234567</mmlCm:Id>

                                                        <mmlPsi:personName>

                                                                <mmlNm:Name mmlNm:repCode = "A"

                                                                        mmlNm:tableId = "MML0025">

                                                                        <mmlNm:family>Tanaka</mmlNm:family>

                                                                        <mmlNm:given>Fujiko</mmlNm:given>

                                                                        <mmlNm:degree>M.D.</mmlNm:degree>

                                                                </mmlNm:Name>

                                                        </mmlPsi:personName>

                                                        <mmlFc:Facility>

                                                                <mmlFc:name mmlFc:repCode = "A"

                                                                        mmlFc:tableId = "MML0025">

                                                                        New Millenium Heisei Hospital</mmlFc:name>

                                                                <mmlCm:Id mmlCm:type = "insurance" mmlCm:tableId = "MML0027">

                                                                        2354678</mmlCm:Id>

                                                        </mmlFc:Facility>

                                                        <mmlDp:Department>

                                                        <mmlDp:name mmlDp:repCode = "A"

                                                                mmlDp:tableId = "MML0025"> Cardiology </mmlDp:name>

                                                                <mmlCm:Id mmlCm:type = "claim" mmlCm:tableId = "MML0029">

                                                                        08</mmlCm:Id>

                                                        </mmlDp:Department>

                                                </mmlPsi:PersonalizedInfo>

                                        </mmlSm:referTo>

                                </mmlSm:discharge>

                                <mmlSm:staffs>

                                        <mmlSm:staffInfo>

                                                <mmlPsi:PersonalizedInfo>

                                                        <mmlCm:Id mmlCm:type = " facility" mmlCm:tableId = "MML0024">

                                                                23456789</mmlCm:Id>

                                                        <mmlPsi:personName>

                                                                <mmlNm:Name mmlNm:repCode = "A" mmlNm:tableId = "MML0025">

                                                                        <mmlNm:family>Araki</mmlNm:family>

                                                                        <mmlNm:given>Kenji</mmlNm:given>

                                                                        <mmlNm:degree>M.D.</mmlNm:degree>

                                                                </mmlNm:Name>

                                                        </mmlPsi:personName>

                                                        <mmlFc:Facility>

                                                                <mmlFc:name mmlFc:repCode = "A"

                                                                        mmlFc:tableId = "MML0025">

                                                                        New Millenium Medical College Hospital </mmlFc:name>

                                                                <mmlCm:Id mmlCm:type = "insurance" mmlCm:tableId = "MML0027">

                                                                        801.006.3</mmlCm:Id>

                                                        </mmlFc:Facility>

                                                        <mmlDp:Department>

                                                                <mmlDp:name mmlDp:repCode = "A" mmlDp:tableId = "MML0025">

                                                                        Cardiovascular surgery

                                                                </mmlDp:name>

                                                                <mmlCm:Id mmlCm:type = " claim" mmlCm:tableId = "MML0029">

                                                                        16</mmlCm:Id>

                                                        </mmlDp:Department>

                                                </mmlPsi:PersonalizedInfo>

                                                <mmlCi:creatorLicense mmlCi:tableId = "MML0026">

                                                        doctor

                                                </mmlCi:creatorLicense>

                                        </mmlSm:staffInfo>

                                </mmlSm:staffs>

                        </mmlSm:inPatientItem>

                </mmlSm:inPatient>

        </mmlSm:serviceHistory>

        <mmlRd:RegisteredDiagnosisModule>

                <mmlRd:diagnosisContents>

                        <mmlRd:dxItem >

                                <mmlRd:name mmlRd:code = "I209-.002" mmlRd:system = "ICD10">

                                        Angina pectoris

                                </mmlRd:name>

                        </mmlRd:dxItem>

                        <mmlRd:dxItem >

                                <mmlRd:name>three vessels disease</mmlRd:name>

                        </mmlRd:dxItem>

                        <mmlRd:dxItem >

                                <mmlRd:name>unstable</mmlRd:name>

                        </mmlRd:dxItem>

                </mmlRd:diagnosisContents>

                <mmlRd:categories>

                        <mmlRd:category mmlRd:tableId = "MML0012">mainDiagnosis</mmlRd:category>

                        <mmlRd:category mmlRd:tableId = "MML0013">academicDiagnosis</mmlRd:category>

                        <mmlRd:category mmlRd:tableId = "MML0014">clinicalDiagnosis </mmlRd:category>

                        <mmlRd:category mmlRd:tableId = "MML0015">confirmedDiagnosis</mmlRd:category>

                </mmlRd:categories>

        </mmlRd:RegisteredDiagnosisModule>

        <mmlSg:SurgeryModule>

                <mmlSg:surgeryItem>

                        <mmlSg:surgicalInfo mmlSg:type = "emergent ">

                                <mmlSg:date>1999-08-27</mmlSg:date>

                        </mmlSg:surgicalInfo>

                        <mmlSg:surgicalDiagnosis>

                                <mmlRd:RegisteredDiagnosisModule>

                                        <mmlRd:diagnosisContents>

                                                <mmlRd:dxItem >

                                                        <mmlRd:name mmlRd:code = "I209-.002" mmlRd:system = "ICD10">

                                                                Angina pectoris

                                                        </mmlRd:name>

                                                </mmlRd:dxItem>

                                                <mmlRd:dxItem >

                                                        <mmlRd:name>three vessels disease</mmlRd:name>

                                                </mmlRd:dxItem>

                                        </mmlRd:diagnosisContents>

                                        <mmlRd:categories>

                                                <mmlRd:category mmlRd:tableId = "MML0012">mainDiagnosis</mmlRd:category>

                                                <mmlRd:category

                                                        mmlRd:tableId = "MML0013">academicDiagnosis</mmlRd:category>

                                                <mmlRd:category

                                                        mmlRd:tableId = "MML0014">operativeDiagnosis</mmlRd:category>

                                                <mmlRd:category

                                                        mmlRd:tableId = "MML0015">confirmedDiagnosis</mmlRd:category>

                                        </mmlRd:categories>

                                </mmlRd:RegisteredDiagnosisModule>

                        </mmlSg:surgicalDiagnosis>

                        <mmlSg:surgicalProcedure>

                                <mmlSg:procedureItem>

                                        <mmlSg:operation>coronary artery bypass grafting</mmlSg:operation>

                                </mmlSg:procedureItem>

                                <mmlSg:procedureItem>

                                        <mmlSg:operation>cardio-pulmonary bypass</mmlSg:operation>

                                </mmlSg:procedureItem>

                        </mmlSg:surgicalProcedure>             

                </mmlSg:surgeryItem>

        </mmlSg:SurgeryModule>

        <mmlSm:chiefComplaints>Severe chest pain</mmlSm:chiefComplaints>

        <mmlSm:patientProfile>

                The patient is a 40-year-old married forester.

        </mmlSm:patientProfile>

        <mmlSm:history>

                On a background of good health, the patient noted the onset of chest pain and dyspnea on Aug 25,1999. At 10 A.M., he was put into the ambulance on a stretcher and driven to our hospital. At arrival, the symptoms subsided and he went home without any medication. Two days ago (Aug 27), he felt intractable chest pain and was referred to the department of cardiovascular surgery under the diagnosis of unstable angina pectoris.

        </mmlSm:history>

        <mmlSm:physicalExam>

                Physical findings were essentially normal except for the blood pressure which was 160/100. Heart sounds were clear and rhythm was regular without audible murmurs or friction sounds.

        </mmlSm:physicalExam>

        <mmlSm:clinicalCourse>

                <mmlSm:clinicalRecord mmlSm:date=”1999-08-27”>

                        Emergency coronary angiography was carried out.

                        <mmlCm:extRef mmlCm:contentType = "image/jpeg"

                                mmlCm:medicalRole = " angioGraphy "

                                mmlCm:title = "Preoperative coronary angiography"

                                mmlCm:href = "patient001/surgicalFigure003.jpg"/>

                        Three vessels (LAD, #9, #12) were involved.

                        ＜mmlSm:relatedDoc mmlSm:relation=” detail”＞

                                11D1AC5400A0C94A814796045F768ED5

                        ＜/mmlSm:relatedDoc＞

                </mmlSm:clinicalRecord>

                <mmlSm:clinicalRecord mmlSm:date=” 1999-08-27”>

                        Emergency operation was performed. Complete revascularization was achieved.

                        <mmlCm:extRef mmlCm:contentType = "image/gif"

                                mmlCm:medicalRole = " surgicalFigure "

                                mmlCm:title = "Grafting"

                                mmlCm:href = "patient001/surgicalFigure002.gif"/>

                        After the successful operation, the patient was transferred to ICU.

                        ＜mmlSm:relatedDoc mmlSm:relation=” surgery”＞

                                0aae5960-667c-11d3-9751-00105a6792e8

                        ＜/mmlSm:relatedDoc＞

                </mmlSm:clinicalRecord>

                <mmlSm:clinicalRecord mmlSm:date=” 1999-08-29”>

                        Postoperative clinical course was well. Rehabilitation program was started.

                </mmlSm:clinicalRecord>

                <mmlSm:clinicalRecord mmlSm:date=” 1999-08-31”>

                        Postoperative clinical course was well. He was transferred to a chronic hospital.

                </mmlSm:clinicalRecord>

        </mmlSm:clinicalCourse>

        <mmlSm:dischargeFindings>

                Symptoms free, no wound infection.

        </mmlSm:dischargeFindings>

        <mmlSm:medication>

                Prescription on discharge

                <mmlCm:extRef

                        mmlCm:contentType = "APPLICATION/HL72.3-HL7ER2.3"

                        mmlCm:medicalRole = "prescription"

                        mmlCm:title = "Prescription on discharge"

                        mmlCm:href = "patient1234/prescription003.HL7"/>

        </mmlSm:medication>

        <mmlSm:testResults>

                <mmlSm:testResult mmlSm:date=” 1999-08-31”>

                        Labo findings on discharge

                        <mmlCm:extRef

                                mmlCm:contentType = "APPLICATION/HL72.3-HL7ER2.3"

                                mmlCm:medicalRole = " laboratoryTest "

                                mmlCm:title = "Blood chemistry data on discharge"

                                mmlCm:href = "patient1234/prescription004.HL7"/>

                </mmlSm:testResult>

                <mmlSm:testResult mmlSm:date=” 1999-08-31”>

                        ECG on discharge. No ST change and no new Q wave was observed.

                        <mmlCm:extRef

                                mmlCm:contentType = "image/gif"

                                mmlCm:medicalRole = " ecg "

                                mmlCm:title = "ECG on discharge"

                                mmlCm:href = "patient1234/exam004.gif"/>

                </mmlSm:testResult>

        </mmlSm:testResults>

        <mmlSm:plan>

                Rehabilitation program and wound care will continue in the chronic hospital. .

        </mmlSm:plan>

        <mmlSm:remarks>

                Patient education: good. Appointment in outpatient department in 2 weeks.

        </mmlSm:remarks>

</mmlSm:SummaryModule>