C.2.4 Patient Medical Module

Table C.2-4 defines the Attributes relevant to a patient's medical state or history.

Table C.2-4PATIENT MEDICAL MODULE ATTRIBUTES

Attribute Name Tag Attribute Description
Medical Alerts (0010,2000) Conditions to which medical staff should be alerted (e.g. contagious condition, drug allergies, etc.)
Allergies (0010,2110) Description of prior reaction to contrast agents, or other patient allergies or adverse reactions.
Smoking Status (0010,21A0) Indicates whether patient smokes. Enumerated Values: YES NO UNKNOWN
Additional Patient History (0010,21B0) Additional information about the patient's medical history
Pregnancy Status (0010,21C0) Describes pregnancy state of patient. Enumerated Values: 0001 = not pregnant 0002 = possibly pregnant 0003 = definitely pregnant 0004 = unknown
Last Menstrual Date (0010,21D0) Date of onset of last menstrual period
Patient’s Sex Neutered (0010,2203) Whether or not a procedure has been performed in an effort to render the patient sterile. Enumerated value: ALTERED = Altered/Neutered UNALTERED = Unaltered/intact
Special Needs (0038,0050) Medical and social needs (e.g. wheelchair, oxygen, translator, etc.)
Patient State (0038,0500) Description of patient state (comatose, disoriented, vision impaired, etc.)
Pertinent Documents Sequence (0038,0100) List of Documents (e.g., SR, or CDA) that contain information considered pertinent for the patient medical condition. Zero or more Items shall be included in this sequence.
>Include SOP Instance Reference Macro Table 10-11
>Purpose of Reference Code Sequence (0040,A170) Describes the purpose for which the document reference is made. Zero or more Items shall be included in this sequence.
>>Include ‘Code Sequence Macro’ Table 8.8-1 No Baseline Context Group ID defined
>Document Title (0042,0010) Title of the referenced document.
Patient Clinical Trial Participation Sequence (0038,0502) Sequence of identifiers for clinical trials in which the patient participates. Zero or more Items shall be included in this sequence.
>Clinical Trial Sponsor Name (0012,0010) The name of the clinical trial sponsor, responsible for conducting the clinical trial and for defining the Clinical Trial Protocol.
>Clinical Trial Protocol ID (0012,0020) Identifier for the noted protocol, used by the Clinical Trial Sponsor to uniquely identify the investigational protocol.
>Clinical Trial Protocol Name (0012,0021) The name or title of the clinical trial protocol.
>Clinical Trial Site ID (0012,0030) The identifier, issued by the Clinical Trial Sponsor, of the site responsible for submitting clinical trial data.
>Clinical Trial Site Name (0012,0031) Name of the site responsible for submitting clinical trial data.
>Clinical Trial Subject ID (0012,0040) The assigned identifier for the patient as a clinical trial subject.
>Clinical Trial Subject Reading ID (0012,0042) Identifies the patient as a clinical trial subject for blinded evaluations.

Note: The Patient Clinical Trial Participation Sequence (0038,0502) identifies potentially multiple trials in which the patient is enrolled. Application behavior in the presence of multiple items is outside the scope of the standard.