Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.4 - EntrySocialHistoryObservation

Template Social History Observation

Template 1.3.6.1.4.1.19376.1.5.3.1.4.13.4 - EntrySocialHistoryObservation

Id 1.3.6.1.4.1.19376.1.5.3.1.4.13.4

Version valid from 2013‑12‑20 status Under develeopment

Classification CDA Entry Level Template

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.13.4

Open/Closed Open (other than defined elements are allowed)

Description

A social history observation is a simple observation that uses a specific vocabulary, and inherits constraints from CCD.

epSOS functional experts limited the social observations to smoke, alcohol and diet related observations.

The parent of this template is Simple Observation . This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.33

Used by / Uses

Used by / Uses 4 templates

Used by Template id	as	Name	Version
1.3.6.1.4.1.19376.1.5.3.1.3.16.1	Containment	SectionCodedSocialHistory Section Coded Social History	2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3		epSOS-PS epSOS-Patient Summary	2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4		epSOS-HCER epSOS-Health Care Encounter Report	2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5		epSOS-MRO epSOS-Medication Related Overview	2013‑12‑20

Relationship Specialization: template 2.16.840.1.113883.10.20.1.33 (DYNAMIC)

Item DT Card Conf Description Label

hl7:observation

(EntrySocialHistoryObservation)

Example <observation typeCode="OBS" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/> <templateId root="2.16.840.1.113883.10.20.1.33"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13.4"/> <id root=" " extension=" "/> <code code=" " displayName=" " codeSystem=" " codeSystemName=" "/> <text> <reference value="#xxx"/> </text> <statusCode code="completed"/> <effectiveTime value=" "/> <repeatNumber value=" "/> <value xsi:type=" "/> <interpretationCode code=" " codeSystem=" " codeSystemName=" "/> <methodCode code=" " codeSystem=" " codeSystemName=" "/> <targetSiteCode code=" " codeSystem=" " codeSystemName=" "/> </observation>

hl7:templateId

II.EPSOS

1 .. 1

(EntrySocialHistoryObservation)

@root

1 .. 1

1.3.6.1.4.1.19376.1.5.3.1.4.13

hl7:templateId

II.EPSOS

1 .. 1

(EntrySocialHistoryObservation)

@root

1 .. 1

2.16.840.1.113883.10.20.1.33

hl7:templateId

II.EPSOS

1 .. 1

(EntrySocialHistoryObservation)

@root

1 .. 1

1.3.6.1.4.1.19376.1.5.3.1.4.13.4

hl7:code

1 .. 1

The <code> element identifies the type social history observation.

The first two columns of following table describe the value set to be used for this attribute, derived from the code systeme SNOMED CT (2.16.840.1.113883.6.96). For each used concept the data type of the “value” attribute, and the related unit, is reported.

CODE	VALUE
Code	displayName	xsi:type	unit
229819007	Smoking	PQ	{pack}/d or {pack}/wk or {pack}/a
256235009	Exercise		{times}/wk
160573003	ETOH (Alcohol) Use		{drink}/d or {drink}/wk
364393001	Nutritional observable	CD	N/A
364703007	Employment detail
425400000	Toxic exposure status
363908000	Details of drug misuse behavior
228272008	Health-related behavior	ANY

(EntrySocialHistoryObservation)

hl7:statusCode

1 .. 1

(EntrySocialHistoryObservation)

@code

1 .. 1

completed

@codeSystem

1 .. 1

2.16.840.1.113883.5.14 (ActStatus)

hl7:repeatNumber

The <repeatNumber> element should not be used in a social history observation.

(EntrySocialHistoryObservation)

hl7:value

ANY

1 .. *

The <value> element reports the value associated with the social history observation. The data type to use for each observation should be drawn from the table above.

Observations in the table above using the PQ data type have a unit in the form {xxx}/d, {xxx}/wk or {xxx}/a represent the number of items per day, week or year respectively. The value attribute indicates the number of times of the act performed, and the units represent the frequency. The example below shows how to represent 1 drink per day.

  <code code='160573003' displayName='ETOH Use'

        codeSystem='2.16.840.1.113883.6.96'

        codeSystemName='SNOMED CT'/>

  <value xsi:type='PQ' value='1' unit='{drink}/d'/>

Observations in the table using the CD data type should include coded values from an appropriate vocabulary to represent the social history item. The example below shows the encoding to indicate drug use of cannabis.

  <code code='363908000' displayName='Drug Use'

        codeSystem='2.16.840.1.113883.6.96'

        codeSystemName='SNOMED CT'/>

  <value xsi:type='CD' code='398705004' displayName='cannabis'

         codeSystem='2.16.840.1.113883.6.96'

         codeSystemName='SNOMED CT'/>

Other social history observations may use any appropriate data type.

(EntrySocialHistoryObservation)

hl7:interpretationCode

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

(EntrySocialHistoryObservation)

hl7:methodCode

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

(EntrySocialHistoryObservation)

hl7:targetSiteCode

The <interpretationCode>, <methodCode>, and <targetSiteCode> elements should not be used in a social history observation.

(EntrySocialHistoryObservation)

Template Social History Observation