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draft Template  Problem Concern

Template 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 - EntryProblemConcern
Id 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Entry Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Open/Closed Open (other than defined elements are allowed)
Description

This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused on a problem. Elements shown in the example below in gray are explained in the Concern Entry.

Parent Template

The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.2, and is a subtype of the Concern Entry, and so must also conform to that specification, with the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.1. These elements are required and shall be recorded exactly as shown.

Used by / Uses
Used by / Uses 8 templates
Used by Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment SectionActiveProblems Section Active Problems 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
1.3.6.1.4.1.19376.1.5.3.1.3.8 Containment SectionHistoryOfPastIllness Section History of Past Illness 2013‑12‑20
Uses Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment EntryProblem DYNAMIC
Item DT Card Conf Description Label
hl7:act
R (EntryProblemConcern)
treetree @classCode
1 .. 1 F ACT
treetree @moodCode
1 .. 1 F EVN
  Example <act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.27"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>
  <id root=" " extension=" "/>
  <code nullFlavor="NA"/>
  <statusCode code="active|suspended|aborted|completed"/>
  <effectiveTime>
    <low value=" "/>
    <high value=" "/>
  </effectiveTime>
  <!-- 1..* entry relationships identifying problems of concern -->
  <entryRelationship type="SUBJ">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
      <templateId root="2.16.840.1.113883.10.20.1.28"/>
      <!-- ... -->
    </observation>
  </entryRelationship>
  <!-- optional entry relationship providing more information about the concern -->
  <entryRelationship type="REFR"/>
</act>
treetree hl7:templateId
II 1 .. 1 M (EntryProblemConcern)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.27
treetree hl7:templateId
II 1 .. 1 M (EntryProblemConcern)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5.1
treetree hl7:templateId
II 1 .. 1 M (EntryProblemConcern)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
treetree hl7:id
II 1 .. * M (EntryProblemConcern)
treetree hl7:code
CD 1 .. 1 R Fixed nullFlavor='NA' (EntryProblemConcern)
treetree hl7:text
ED 0 .. 1 R (EntryProblemConcern)
treetree hl7:statusCode
CS 0 .. 1 R One of: active|suspended|aborted|completed (EntryProblemConcern)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.159331 ActStatus (DYNAMIC)
treetree hl7:effectiveTime
IVL_TS 0 .. 1 R The <low> element shall be present, The <high> element shall be present for concerns in the completed or aborted state, and shall not be present otherwise. (EntryProblemConcern)
treetree hl7:entryRelationship
where
[hl7:observation [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.5' and hl7:templateId/@root='2.16.840.1.113883.10.20.1.28']]
1 .. * R

This entry shall contain one or more problem entries that conform to the Problem Entry template 1.3.6.1.4.1.19376.1.5.3.1.4.5. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

Note: every Problem Entry used in this section to identify problem of concern MAY have an <entryRelationship> that will indicate the severity of the problem, conforming to the severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1). The severity codes to be used are epSOSSeverity, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.13.

(EntryProblemConcern)
treeblank treetree @typeCode
1 .. 1 F SUBJ
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC)
treetree hl7:entryRelationship
0 .. * R optional entry relationship providing more information about the concern. A source of information observation SHALL be the target of an entryRelationship whose value for “entryRelationship / @typeCode” SHALL be “REFR” “Refers to” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC. A source of information observation SHALL be represented with Observation. CONF‑524 / CONF‑525
treeblank treetree @typeCode
1 .. 1 F REFR
treeblank treetree hl7:observation
ASTM CCR requires that all data objects have a stated source (or state explicitly that the source is unknown) so that any data within the summary can be validated. The source of data may be a person, organization, reference to some other data object, etc. CONF‑524 / CONF‑525
treeblank treeblank treetree @classCode
0 .. 1 F OBS
  The value for “Observation / @classCode” in a source of information observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
treeblank treeblank treetree @moodCode
0 .. 1 F EVN
  The value for “Observation / @moodCode” in a source of information observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
treeblank treeblank treetree hl7:code
CD 1 .. 1 R A source of information observation SHALL contain exactly one Observation / code. The value for “Observation / code” in a source of information observation SHALL be “48766-0” “Information source” 2.16.840.1.113883.6.1 LOINC STATIC. CONF‑530 / CONF‑531
treeblank treeblank treeblank treetree @code
1 .. 1 F 48766-0
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treeblank treeblank treeblank treetree @displayName
1 .. 1 F Information source
treeblank treeblank treetree hl7:statusCode
1 .. 1 R A source of information observation SHALL contain exactly one Observation / statusCode. The value for “Observation / statusCode” in a source of information observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC. CONF‑528 / CONF‑529
treeblank treeblank treeblank treetree @code
1 .. 1 F completed
treeblank treeblank treetree hl7:value
1 .. 1 M A source of information observation SHALL contain exactly one Observation / value. The absence of a known source of information SHALL be explicity asserted by valuing Observation / value in a source of information observation with the text string “Unknown”. CONF‑532 / CONF‑533