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draft Template  Entry Health Status Observation

Template 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 - EntryHealthStatusObservation
Id 1.3.6.1.4.1.19376.1.5.3.1.4.1.2
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Entry Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.1.2
Open/Closed Open (other than defined elements are allowed)
Description A problem observation may reference a health status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The health status observation records information about the current health status of the patient. The example below shows the recording the health status, and is used as the context for the following sections.
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="2.16.840.1.113883.10.20.1.51"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.2"/>
  <code code="11323-3" displayName="Health Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
  <text>
    <reference value="#hstatus-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
(EntryHealthStatusObservation)
treetree @classCode
0 .. 1 F OBS
treetree @moodCode
0 .. 1 F EVN
treetree hl7:templateId
II 1 .. 1 R (EntryHealthStatusObservation)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.51
treetree hl7:templateId
II 1 .. 1 R (EntryHealthStatusObservation)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.1.2
treetree hl7:code
CD 1 .. 1 R

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

(EntryHealthStatusObservation)
treeblank treetree @code
1 .. 1 F 11323-3
treeblank treetree @displayName
1 .. 1 F Health Status
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
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.

(EntryHealthStatusObservation)
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.

(EntryHealthStatusObservation)
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 health 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. (EntryHealthStatusObservation)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.30 epSOSResolutionOutcome (DYNAMIC)