11. 9. Clinical summary information module
Element structure

 

 

 

Namespace declaration

Namespace declaration of this module is as follows.

xmlns:mmlSm="http://www.medxml.net/MML/ContentModule/Summary/1.0"

Element list

 

Element

Attribute

Data type

Occurrence

Table

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; blank: 1 appearance without fail, ?: 0 or 1 appearance, +: 1 or more appearances, *: 0 or more appearances

#REQUIRED: Required attribute, #IMPLIED: Omissible attribute

Management

The clinical summary information groups various items of information (progress course, patient information, diagnosis, surgery, etc.). The following methods are available for the creation of a group.

Method 1:

Information on diagnoses and surgeries can be entered in the mmlSm:SummaryModule, not in external references or links.

Method 2:

The mmlSm:SummaryModule and related modules (patient information, diagnosis, surgery, etc.) can be compiled into a single MML instance with repetition of <paragraph>s, not using an external reference or link. In this case, enter “summary” in the extractPolicy (an attribute of the scopePeriod in the docInfo module) to define the data as a general summary.

Method 3:

Use the link function between documents using the MML groupId. More specifically, enter the same uid in the groupId of the related modules (patient information, diagnosis, surgery, etc.) including the mmlSm:SummaryModule. It is not necessary to compile the data into a single MML instance. Specify the appropriate document type in the groupClass attribute of the groupId.
 

Method 3 is most recommended. The reasons for this are firstly that diagnosis or surgery information entered in the mmlSm:SummaryModule via method 1 is difficult to search or reuse and that, secondly, in the case of method 2 it is difficult to control information in the module unit. In method 3, since diagnosis or surgery information is considered to be an independent module, it is easy to carry out a search or make use of the information; links will not be lost even when the information is controlled in the module unit because of the existence of the groupId.

Element explanation

1.mmlSm:SummaryModule

Description: clinical summary information

1.1.mmlSm:serviceHistory

Description: period information. This module is not necessarily limited to one admission to hospital. Multiple admissions to hospital, visits to outpatient clinic, and the combinations of both may also be included.

Omission: not allowed

Attribute:

Attribute name

Data type

Omission

Remarks

mmlSm:start

date

#IMPLIED

Start date of a summary period

mmlSm:end

date

#IMPLIED

End date of a summary period

Usually, the values of attributes above will be the same as those of the “start” and “end” attributes of the docInfo module, .confirmDate.

Example:

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

Example: summary of one year

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

1.1.1.mmlSm:outPatient

Description: outpatient history information

Omission: allowed

1.1.1.1.mmlSm:outPatientItem

Description: individual outpatient history item

Omission: allowed

Repetition: allowed. If there are multiple visits as outpatients, the element should be repeated.

1.1.1.1.1.mmlSm:date

Description: outpatient visit date

Data type: date Format: CCYY-MM-DD

Omission: not allowed

Example: visit to outpatient clinic on August 25.

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

1.1.1.1.2.mmlSm:outPatientCondition

Description: condition at an outpatient visit

Data type: string

Omission: allowed

Attribute:

Attribute name

Data type

Omission

Remarks

mmlSm:first

boolean

#IMPLIED

Indication of the first time visit. true: First time visit, false: Revisit

mmlSm:emergency

boolean

#IMPLIED

Indication of an emergency visit. true: Emergency, false: Normal
 

Example: for the first and emergency visit

<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

Description: information on staff for a patient

Omission: allowed

1.1.1.1.3.1.mmlSm:staffInfo

Description: staff for an outpatient

Omission: not allowed

Repetition: allowed. If multiple members of staff are available, the element should be repeated.

1.1.1.1.3.1.1.mmlPsi:PersonalizedInfo

Description: personal information. Refer to the MML common format for the structure.

Omission: not allowed

1.1.1.1.3.1.2.mmlCi:creatorLicense

Description: staff license

Data type: string

Omission: not allowed

Repetition: allowed. If multiple licenses are available, the element should be repeated.

1.1.2.mmlSm:inPatient

Description: inpatient history information

Omission: not allowed

1.1.2.1.mmlSm:inPatientItem

Description: individual inpatient history item. Multiple admissions to hospital, ward transfer and change of department in one admission to hospital may be described by repetition.

Omission: allowed

Repetition: allowed. If there are multiple admissions, the element should be repeated.

1.1.2.1.1.mmlSm:admission

Description: admission to hospital

Omission: not allowed

1.1.2.1.1.1.mmlSm:date

Description: admission (or transfer) date

Data type: date Format: CCYY-MM-DD

Omission: not allowed

Example: admission on August 27,1999

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

1.1.2.1.1.2.mmlSm:admissionCondition

Description: condition at time of admission to hospital

Data type: string

Omission: allowed

Attribute:

Attribute name

Data type

Omission

Remarks

mmlSm:emergency

boolean

#IMPLIED

Indication of an emergency admission. true: Emergency, false: Normal
 

Example: emergency admission by ambulance

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

Emergency admission by ambulance

</mmlSm:admissionCondition>

1.1.2.1.1.3.mmlSm:referFrom

Description: referring physician information

Omission: allowed

1.1.2.1.1.3.1.mmlPsi:PersonalizedInfo

Description: personal information. Refer to the MML common format for the structure.

Omission: not allowed

Example: referring from Yoko Ono M.D., Internal Medicine, New Millennium Medical College

<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 = "medical" mmlCm:tableId = "MML0029">01</mmlCm:Id>

</mmlDp:Department>

</mmlPsi:PersonalizedInfo>

</mmlSm:referFrom>

1.1.2.1.2.mmlSm:discharge

Description: discharge from hospital

Omission: not allowed

1.1.2.1.2.1.mmlSm:date

Description: discharge (or transfer) date

Data type: date Format: CCYY-MM-DD

Omission: not allowed

Example: discharge on August 31,1999

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

1.1.2.1.2.2.mmlSm:dischargeCondition

Description: condition at time of discharge from hospital

Data type: string

Omission: allowed

Attribute:

Attribute name

Data type

Omission

Table

Remarks

mmlSm:outcome

string

#IMPLIED

MML0016

Outcome at time of discharge
 

Example: a case that the patient is transferred to the chronic hospital on the 4th post operative day.

<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

Description: consulted physician information

Omission: not allowed

1.1.2.1.2.3.1.mmlPsi:PersonalizedInfo

Description: personal information. Refer to the MML common format for the structure.

Omission: not allowed

Example: referring to Fujiko Tanaka M.D., Cardiology, New Millennium Heisei Hospital

<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 = "medical" mmlCm:tableId = "MML0029">08</mmlCm:Id>

</mmlDp:Department>

</mmlPsi:PersonalizedInfo>

</mmlSm:referTo>

1.1.2.1.3.mmlSm:staffs

Description: information on staff for a patient

Omission: allowed

1.1.2.1.3.1.mmlSm:staffInfo

Description: staff for an inpatient

Omission: not allowed

Repetition: allowed. If multiple members of staff are available, the element should be repeated.

1.1.2.1.3.1.1.mmlPsi:PersonalizedInfo

Description: personal information. Refer to the MML common format for the structure.

Omission: not allowed

1.1.2.1.3.1.2.mmlCi:creatorLicense

Description: staff license

Data type: string

Omission: not allowed

Repetition: allowed. If multiple licenses are available, the element should be repeated.

Example: the doctor in charge of the patient at the time of admission is Kenji Araki M.D., Cardiovascular surgery, New Millennium Medical College Hospital.

<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 = " medical" mmlCm:tableId = "MML0029">16</mmlCm:Id>

</mmlDp:Department>

</mmlPsi:PersonalizedInfo>

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

</mmlSm:staffInfo>

1.2.mmlRd:RegisteredDiagnosisModule

Description: diagnosis record information in a summary. Refer to the aforementioned explanation for the structure.

Refer to the management section above. Use this element in method 1. In methods 2 and 3, this element is omitted.

Omission: allowed

Repetition: allowed. If multiple diagnoses are available, the element should be repeated.

1.3.mmlSm:deathInfo

Description: death related information

Data type: string

Omission: allowed

Attribute:

Attribute name

Data type

Omission

Remarks

mmlSm:date

date/dateTime

#IMPLIED

Date and time of death

mmlSm:autopsy

boolean

#IMPLIED

Whether or not an autopsy is carried out. true: Autopsy, false: No autopsy

Example: died of gastric cancer on August 31,1999. Autopsy performed.

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

The patient died of gastric cancer.

</mmlSm:deathInfo>

1.4.mmlSg:SurgeryModule

Description: surgery record information in a summary. Refer to the aforementioned explanation for the structure.

Refer to the management section above. Use this element in method 1. In methods 2 and 3, this element is omitted.

Omission: allowed

Repetition: allowed. If multiple surgeries are performed, the element should be repeated.

1.5.mmlSm:chiefComplaints

Description: chief complaint

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

Example:

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

1.6.mmlSm:patientProfile

Description: patient profile

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

Example:

<mmlSm:patientProfile>

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

</mmlSm:patientProfile>

1.7.mmlSm:history

Description: history before admission

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

Example:

<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

On 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

Description: physical findings at time of admission

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

Example:

<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

Description: refer to the MML common format (External reference format) for the structure.

Omission: allowed

Repetition: allowed. If multiple external references are available, the element should be repeated the number of times.

1.9.mmlSm:clinicalCourse

Description: clinical course and treatment

Omission: allowed

1.9.1.mmlSm:clinicalRecord

Description: clinical record. This can be present together with the mmlCm:extRef and mmlSm:relatedDoc.

Data type: string

Omission: not allowed

Repetition: allowed. The element should be repeated the corresponding number of times to dates or items.

Document layout: use of XHTML is allowed.

Attribute:

Attribute name

Data type

Omission

Remarks

mmlSm:date

date/dateTime

#IMPLIED

Date and time of an event occurrence

1.9.1.1.mmlCm:extRef

Description: refer to the MML common format (External reference format) for the structure.

Omission: allowed

Repetition: allowed. If multiple external references are available, the element should be repeated the number of times.

1.9.1.2. mmlSm:relatedDoc

Description: enter the uid of a <paragraph> in an MML document related to this clinical record.

Data type: string

Omission: allowed

Repetition: allowed. If multiple related documents are available, the element should be repeated.

Attribute:

Attribute name

Data type

Omission

Table

Remarks

mmlSm:relatedDoc

string

#IMPLIED

MML0008

Document relation type

Example:

<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.

ÅÉmmlSm:relatedDoc mmlSm:relation=" detail"ÅÑ

11D1AC5400A0C94A814796045F768ED5ÅÉ/mmlSm:relatedDocÅÑ

</mmlSm:clinicalRecord>

</mmlSm:clinicalCourse>

1.10.mmlSm:dischargeFindings

Description: findings at time of discharge. This can be present together with the mmlCm:extRef.

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

1.10.1.mmlCm:extRef

Description: refer to the MML common format (External reference format) for the structure.

Omission: allowed

Repetition: allowed. If multiple external references are available, the element should be repeated the number of times.

Example:

<mmlSm:dischargeFindings>

Symptoms free, no wound infection.

</mmlSm:dischargeFindings>

1.11.mmlSm:medication

Description: prescription at time of discharge. This can be present together with the mmlCm:extRef.

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

1.11.1.mmlCm:extRef

Description: refer to the MML common format (External reference format) for the structure.

Omission: allowed

Description: refer to the MML common format (External reference format) for the structure.

Example:

<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

Description: test result at time of discharge

Omission: allowed

1.12.1.mmlSm:testResult

Description: individual test result. This can be present together with the mmlCm:extRef.

Data type: string

Omission: not allowed

Repetition: allowed. If multiple tests are available, the element should be repeated.

Document layout: use of XHTML is allowed.

1.12.1.1.mmlCm:extRef

Description: refer to the MML common format (External reference format) for the structure.

Omission: allowed

Repetition: allowed. If multiple external references are available, the element should be repeated the number of times.

Example:

<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

Description: treatment plan after discharge. This can be present together with the mmlCm:extRef.

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

1.13.1.mmlCm:extRef

Description: refer to the MML common format (External reference format) for the structure.

Omission: allowed

Repetition: allowed. If multiple external references are available, the element should be repeated the number of times.

Example:

<mmlSm:plan>

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

</mmlSm:plan>

1.14.mmlSm:remarks

Description: remarks for a patient

Data type: string

Omission: allowed

Document layout: use of XHTML is allowed.

Example:

<mmlSm:remarks>

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

</mmlSm:remarks>

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