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draft Template  Entry Problem Status Observation

Template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 - EntryProblemStatusObservation
Id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Entry Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
Open/Closed Open (other than defined elements are allowed)
Description

(CCD) Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

This CCD models a problem status observation as a separate observation from the problem, allergy or medication observation. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify problem status in the coded condition observation, and a separate clinical status observation is no longer necessary. The use of qualifiers in the problem observation is not precluded by this specification or by CCD. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that problem status information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

Used by / Uses
Used by / Uses 20 templates
Used by Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment EntryProblem Problem 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.12 link EntryImmunizations Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23 link SectionImmunizations Section Immunizations 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link epSOS-PS epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link epSOS-HCER epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link epSOS-MRO epSOS-Medication Related Overview 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 link EntryProblemConcern Problem Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.6 link SectionActiveProblems Section Active Problems 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8 link SectionHistoryOfPastIllness Section History of Past Illness 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6 link EntryAllergyAndIntolerance Allergies And Intolerances 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 link EntryAllergyAndIntoleranceConcern Allergy and Intolerance Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13 link SectionAllergiesAndOtherAdverseReactions Section Allergies and Other Adverse Reactions 2013‑12‑20
Example <observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.57"/>
  <templateId root="2.16.840.1.113883.10.20.1.50"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.1"/>
  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <text>
    <reference value="#cstatus-2"/>
  </text>  <statusCode code="completed"/>
  <value xsi:type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
</observation>
Item DT Card Conf Description Label
hl7:observation
(EntryProblemStatusObservation)
treetree @classCode
0 .. 1 F OBS
treetree @moodCode
0 .. 1 F EVN
treetree hl7:templateId
II 1 .. 1 R (EntryProblemStatusObservation)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.57
treetree hl7:templateId
II 1 .. 1 R (EntryProblemStatusObservation)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.50
treetree hl7:templateId
II 1 .. 1 R (EntryProblemStatusObservation)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
treetree hl7:code
CD 1 .. 1 R

This observation is of clinical status, as indicated by the <code> element. This element must be present.

(EntryProblemStatusObservation)
treeblank treetree @code
1 .. 1 F 33999-4
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treeblank treetree @displayName
1 .. 1 F Status
treeblank treetree @codeSystemName
1 .. 1 F LOINC
treetree hl7:text
ED 1 .. 1 M

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

(EntryProblemStatusObservation)
treetree hl7:statusCode
CS 0 .. 1 R

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

(EntryProblemStatusObservation)
treeblank treetree @code
1 .. 1 F completed
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.14 (ActStatus)
treetree hl7:value
CE.EPSOS 1 .. 1 R The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT. (EntryProblemStatusObservation)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.15 epSOSStatusCode (DYNAMIC)