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draft Template  Section Allergies and Other Adverse Reactions

Template 1.3.6.1.4.1.19376.1.5.3.1.3.13 - SectionAllergiesAndOtherAdverseReactions
Id 1.3.6.1.4.1.19376.1.5.3.1.3.13
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Section Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.3.13
Open/Closed Open (other than defined elements are allowed)
Description

The adverse and other adverse reactions section shall contain a narrative description of the substance intolerances and the associated adverse reactions suffered by the patient. It shall include entries for intolerances and adverse reactions as described in the Entry Content Modules.

The parent of this template is CCD 3.8. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.2

The field "alerts" was originally defined to include all the important and objective medical information that should be highlighted (such as allergies, thrombosis risk, immune deficit …etc). When defining the content only allergies and intolerance to drugs appear to be the common understanding and the easiest to be transferred. A lot of surveys are being made in different countries (not only in Europe) to make a more evidence-based definition of what should represented and should not byt the concept “alerts”, hence not enough information could be provided to take a further decision. As epSOS’s intention is not to duplicate information, this shall not be repeated. Alerts are difiucult to represent since they are contextual. Alerts may be represented as severe or life-threatening allergies or other adverse reactions. Another area are certain selected procedures and implanted devivces. The section Allergies and Other Adverse Reactions contains the medical alerts as well, based on the serverity, and their representation becomes a Country B choice.

Used by / Uses
Used by / Uses 4 templates
Used by Template id as Name Version
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 Containment epSOS-PS epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 Containment epSOS-HCER epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 Containment epSOS-MRO epSOS-Medication Related Overview 2013‑12‑20
Uses Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 Containment EntryAllergyAndIntoleranceConcern DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.20.1.2 (DYNAMIC)
Item DT Card Conf Description Label
hl7:section
1 .. 1 M (SectionAllergiesAndOtherAdverseReactions)
treetree @classCode
0 .. 1 F DOCSECT
  Example <component>
  <section>
    <templateId root="2.16.840.1.113883.10.20.1.2"/>
    <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.13"/>
    <id root=" " extension=" "/>
    <code code="48765-2" displayName="Allergies, adverse reactions, alerts" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
    <title>Allergies and Other Adverse Reactions</title>    <text>Text as described above</text>    <entry>
      <!-- ... -->
      <!-- Required Allergies and Intolerances Concern element -->
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.3"/>
      <!-- ... -->
    </entry>  </section></component>
treetree hl7:templateId
II.EPSOS 1 .. 1 M Allergies and Other Adverse Reactions (SectionAllergiesAndOtherAdverseReactions)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.13
treetree hl7:templateId
II.EPSOS 1 .. 1 M CCD 3.8 (SectionAllergiesAndOtherAdverseReactions)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.2
treetree hl7:id
II.EPSOS 1 .. 1 R (SectionAllergiesAndOtherAdverseReactions)
treetree hl7:code
CE.EPSOS 1 .. 1 M Allergies, adverse reactions, alerts (SectionAllergiesAndOtherAdverseReactions)
treeblank treetree @code
1 .. 1 F 48765-2
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree hl7:title
ST 1 .. 1 M Allergies and Other Adverse Reactions (SectionAllergiesAndOtherAdverseReactions)
treetree hl7:text
SD.TEXT 1 .. 1 M Section text (SectionAllergiesAndOtherAdverseReactions)
treetree hl7:entry
where
[hl7:act [hl7:templateId/@root='2.16.840.1.113883.10.20.1.27' and hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.5.1' and hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3']]
0 .. 1 R (SectionAllergiesAndOtherAdverseReactions)
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5.3 Allergy and Intolerance Concern (DYNAMIC)