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--==================MTOM==================
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<id root="7649C5FA-A444-49A6-91E9-78D2E5880C67"/>
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<code code="48765-2" displayName="Allergies et hypersensibilités"
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codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
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<title>Allergies et hypersensibilités</title>
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<text>
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<table border="0">
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<thead>
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<tr>
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<th>Date</th>
|
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<th>Type d'allergie</th>
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<th>Agent responsable</th>
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<th>Statut</th>
|
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</tr>
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</thead>
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<tr>
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<td>03/06/2018</td>
|
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<td><content ID="allergie-001-type">Allergie médicamenteuse</content></td>
|
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<td><content ID="allergie-001-agent">Paracétamol</content></td>
|
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<td><content ID="allergie-001-statut">Intermittent</content></td>
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</tr>
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</tbody>
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<code code="DALG" displayName="Allergie à un produit pharmaceutique"
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<participant typeCode="CSM">
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<participantRole classCode="MANU">
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<code code="60234100" displayName="PARACETAMOL"
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<name/>
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<entryRelationship typeCode="REFR" inversionInd="false">
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<text><reference value="#allergie-001-statut"/></text>
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<statusCode code="completed"/>
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<component>
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<id root="56BFF75D-EA45-43AB-A2D4-B9A67CDEF8C0"/>
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<code code="57207-3" displayName="Facteurs de risque présents ou passés affectant l'état de santé et/ou une circonstance"
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|
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<title>Facteurs de risque</title>
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<component>
|
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<section>
|
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<id root="D99F46A4-C196-44CC-9F77-CB034DF6D1AF"/>
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<code code="29762-2" displayName="Habitus, Mode de vie"
|
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codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
|
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<title>Mode de vie</title>
|
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<text>
|
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<table border="0">
|
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<thead>
|
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<tr>
|
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<th>Type</th>
|
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<th>Observation</th>
|
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</tr>
|
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</thead>
|
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<tbody>
|
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<tr>
|
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<td><content ID="tabac">Consommation tabagique</content></td><td>25 {pack}/a</td>
|
932 |
</tr>
|
933 |
<tr>
|
934 |
<td><content ID="drogue">Consommation de drogue</content></td><td>Consommation de cannabis occasionnelle</td>
|
935 |
</tr>
|
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</tbody>
|
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</table>
|
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</text>
|
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|
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<entry>
|
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<observation classCode="OBS" moodCode="EVN">
|
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|
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<templateId root="2.16.840.1.113883.10.20.1.33" />
|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" />
|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.4" />
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<id root="CF5B21BC-387A-44AD-9FE9-D6582A6CF332"/>
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<code code="74011-8" displayName="Consommation tabagique"
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<text><reference value="#tabac"/></text>
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<statusCode code="completed"/>
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<effectiveTime nullFlavor="NA"/>
|
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<value xsi:type="PQ" value="25" unit="{pack}/a"/>
|
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</observation>
|
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</entry>
|
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|
960 |
<entry>
|
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<observation classCode="OBS" moodCode="EVN">
|
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|
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|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13" />
|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.4" />
|
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|
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|
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<id root="8378F25F-7EC2-4CEE-A9A5-168030827D07"/>
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<code code="42831-8" displayName="Consommation de drogue"
|
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|
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<text><reference value="#drogue"/></text>
|
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<statusCode code="completed"/>
|
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<effectiveTime nullFlavor="NA"/>
|
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<value xsi:type="CD" code="8063-14-7" displayName="Cannabis" codeSystem="1.2.250.1.213.2.72" codeSystemName="ChemIDPlus">
|
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<originalText><reference value="#drogue"/></originalText>
|
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</value>
|
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</observation>
|
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|
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</section>
|
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</component>
|
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|
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<component>
|
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<section>
|
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|
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|
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|
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<templateId root="1.2.250.1.213.1.1.2.74"/>
|
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<id root="BC6A2067-884F-4D55-8B27-E8C2BE276F29"/>
|
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<code code="10161-8" displayName="Facteurs de risques professionnels"
|
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codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
|
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<title>Facteurs de risques professionnels</title>
|
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<text>
|
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<table border="0">
|
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<thead>
|
998 |
<tr>
|
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<th>Type</th>
|
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</tr>
|
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</thead>
|
1002 |
<tbody>
|
1003 |
<tr>
|
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<td>Exposition à l'amiante à contrôler (architecte, reconstruction d'immeubles, visites de chantier)</td>
|
1005 |
</tr>
|
1006 |
</tbody>
|
1007 |
</table>
|
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</text>
|
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</section>
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</component>
|
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<component>
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<section>
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|
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<templateId root="2.16.840.1.113883.10.20.1.4"/>
|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.14"/>
|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.15"/>
|
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|
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<templateId root="1.2.250.1.213.1.1.2.139"/>
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<id root="B6B00F3F-40A0-419F-847F-FDA1E0908EC8"/>
|
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<code code="10157-6" displayName="Historique des pathologies familiales"
|
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codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
|
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<title>Antécédents familiaux</title>
|
1027 |
<text>
|
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<table border="0">
|
1029 |
<thead>
|
1030 |
<tr>
|
1031 |
<th>Lien de parenté</th><th>Antécédent</th>
|
1032 |
</tr>
|
1033 |
</thead>
|
1034 |
<tbody>
|
1035 |
<tr>
|
1036 |
<td><content ID="antecedent-familial-001-sujet">Mère</content></td>
|
1037 |
<td><content ID="antecedent-familial-001-probleme">Anémie drépanocytaire </content></td>
|
1038 |
</tr>
|
1039 |
</tbody>
|
1040 |
</table>
|
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</text>
|
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|
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<entry>
|
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<organizer classCode="CLUSTER" moodCode="EVN">
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|
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<statusCode code="completed"/>
|
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|
1053 |
<subject typeCode="SBJ">
|
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|
1055 |
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|
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<templateId root="1.2.250.1.213.1.1.3.60"/>
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<relatedSubject classCode="PRS">
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<code code="MTH" displayName="Mère"
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<reference value="#antecedent-familial-001-sujet"/>
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</originalText>
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</code>
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<subject>
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|
1067 |
</subject>
|
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</relatedSubject>
|
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</subject>
|
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|
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|
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<component typeCode="COMP">
|
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<observation classCode="OBS" moodCode="EVN">
|
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|
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<templateId root="2.16.840.1.113883.10.20.1.22"/>
|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>
|
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|
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<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.3"/>
|
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|
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<id root="6F3F483F-374C-4CE2-9127-EA1B285E72D2"/>
|
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|
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<code code="282291009" displayName="interprétation diagnostique" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
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<text><reference value="#antecedent-familial-001-probleme"/></text>
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<statusCode code="completed"/>
|
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|
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<value xsi:type="CD" code="D57.1" displayName="Anémie drépanocytaire"
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codeSystem="2.16.840.1.113883.6.3" codeSystemName="CIM10">
|
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<originalText>
|
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<reference value="#antecedent-familial-001-probleme"/>
|
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</originalText>
|
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</value>
|
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|
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|
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</organizer>
|
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|
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</section>
|
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</component>
|
1100 |
|
1101 |
</section>
|
1102 |
</component>
|
1103 |
|
1104 |
</section>
|
1105 |
</component>
|
1106 |
|
1107 |
|
1108 |
<component>
|
1109 |
<section>
|
1110 |
|
1111 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.27"/>
|
1112 |
|
1113 |
<templateId root="1.2.250.1.213.1.1.2.150"/>
|
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<id root="8EB396A9-79A4-4716-BF9D-38F5CE2652E3"/>
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<code code="30954-2" displayName="Résultats d'examens"
|
1116 |
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
|
1117 |
<title>Points de vigilance</title>
|
1118 |
<text>
|
1119 |
<table border="0">
|
1120 |
<tbody>
|
1121 |
<tr><td>ECG Hémibloc antérieur gauche</td></tr>
|
1122 |
<tr><td>Echodoppler VG non dilaté, trouble de la relaxation du VG</td></tr>
|
1123 |
<tr><td>Hypertriglycéridémie avec VLDL élevés - notion familiale ?</td></tr>
|
1124 |
</tbody>
|
1125 |
</table>
|
1126 |
</text>
|
1127 |
</section>
|
1128 |
</component>
|
1129 |
|
1130 |
|
1131 |
<component>
|
1132 |
<section>
|
1133 |
|
1134 |
<templateId root="1.2.250.1.213.1.1.2.32"/>
|
1135 |
<id root="F0147DC8-77FE-4513-A5BD-D90F431BEE68"/>
|
1136 |
<code code="18776-5" displayName="Plan de traitement"
|
1137 |
codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
|
1138 |
<title>Traitement au long cours</title>
|
1139 |
|
1140 |
|
1141 |
<component>
|
1142 |
<section>
|
1143 |
|
1144 |
<templateId root="2.16.840.1.113883.10.20.1.8"/>
|
1145 |
|
1146 |
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.19"/>
|
1147 |
|
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<templateId root="1.2.250.1.213.1.1.2.143"/>
|
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<code code="10160-0" displayName="Traitements"
|
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codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
|
1151 |
<title>Traitements</title>
|
1152 |
<text>
|
1153 |
<table border="0">
|
1154 |
<thead>
|
1155 |
<tr>
|
1156 |
<th>Date de début</th>
|
1157 |
<th>Date de fin</th>
|
1158 |
<th>Médicament</th>
|
1159 |
<th>Posologie</th>
|
1160 |
<th>Voie d'administration</th>
|
1161 |
<th>Motif</th>
|
1162 |
</tr>
|
1163 |
</thead>
|
1164 |
<tbody>
|
1165 |
<tr>
|
1166 |
<td>11/08/2019</td>
|
1167 |
<td>-</td>
|
1168 |
<td><content ID="med-001-pdt">PLAVIX 75mg, comprimé pelliculé</content></td>
|
1169 |
<td>1 cp/j</td>
|
1170 |
<td><content ID="med-001-voie">Voie orale</content></td>
|
1171 |
<td><content ID="med-001-motif">Angine de poitrine instable</content></td>
|
1172 |
</tr>
|
1173 |
<tr>
|
1174 |
<td>11/08/2019</td>
|
1175 |
<td>-</td>
|
1176 |
<td><content ID="med-002-pdt">COUMADINE 5mg, comprimé sécable </content></td>
|
1177 |
<td>1 cp/j</td>
|
1178 |
<td><content ID="med-002-voie">Voie orale</content></td>
|
1179 |
<td><content ID="med-002-motif">Accident Ischémique Cérébral Transitoire</content></td>
|
1180 |
</tr>
|
1181 |
</tbody>
|
1182 |
</table>
|
1183 |
</text>
|
1184 |
|
1185 |
|
1186 |
<entry typeCode="DRIV">
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