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draft Template  Allergies And Intolerances

Template 1.3.6.1.4.1.19376.1.5.3.1.4.6 - EntryAllergyAndIntolerance
Id 1.3.6.1.4.1.19376.1.5.3.1.4.6
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Entry Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.6
Open/Closed Open (other than defined elements are allowed)
Description

Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA <observation> element, with classCode='OBS'. They follow the same pattern as the problem entry, with exceptions noted below.

Parent Template

This is a specialization of the IHE PCC Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5 and of the CCD alert observation template 2.16.840.1.113883.10.20.1.18

Used by / Uses
Used by / Uses 8 templates
Used by Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 Containment 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
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
Uses Template id as Name Version
2.16.840.1.113883.3.1937.777.10.10.134 Containment CDAParticipantBody DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment EntryProblem DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1 Containment EntrySeverity DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.20.1.18 (DYNAMIC)
Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (DYNAMIC)
Item DT Card Conf Description Label
hl7:observation
R

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.6, and is a subtype of the Problem Entry, and so must also conform to the rules of the problem entry, which has the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5. These elements are required and shall be recorded exactly as shown above.

Note: the 1.3.6.1.4.1.19376.1.5.3.1.4.5 requires that also the template ID '2.16.840.1.113883.10.20.1.28' is included.

(EntryAllergyAndIntolerance)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree @negationInd
bl 0 .. 1  
  Example <observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="2.16.840.1.113883.10.20.1.18"/>
  <templateId root="2.16.840.1.113883.10.20.1.28"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
  <id root=" " extension=" "/>
  <!-- This is the code that shows what kind of allergy or intolerance derived from the epSOSAdverseEventType Value Set-->
  <code code="" codeSystem="2.16.840.1.113883.6.96"/>
  <text>
    <reference value=" "/>
  </text>  <statusCode code="completed"/>
  <effectiveTime>
    <low value=" "/>
    <high value=" "/>
  </effectiveTime>  <!-- value element is present only to indicate no known allergies, in all other cases is used for referenicng text in the narrative -->
  <value xsi:type="CD"/>
  <!-- This is the allergen - the substance that caused the allergy -->
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code=" " codeSystem=" ">
          <originalText>
            <reference value="#substance"/>
          </originalText>        </code>        <name/>
      </playingEntity>    </participantRole>  </participant>  <!-- This is how the allergy manifests itself -->
  <entryRelationship typeCode="MFST">
    <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6.1"/>
    <!-- a problem entry -->
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.54"/>
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
      <!-- The code tells us that the observation is a symptom -->
      <code code="418799008" codeSystem="2.16.840.1.113883.6.96" displayName="Finding reported by subject or history provider" codeSystemName="SNOMED CT"/>
      <text>
        <reference value="#manifest-1"/>
      </text>      <statusCode code="completed"/>
      <!-- The value tells us what the symptom (i.e. allergy manifestation) is -->
      <!-- This is where anaphylaxy or angiooedema will be coded -->
      <value xsi:type="CD" code=" " codeSystem=" " displayName=" " codeSystemName=" "/>
    </observation>  </entryRelationship>  <!-- This is how the severity of the allergy is described (Optional)-->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>
      <!-- This code is from HL7 and indicates that the observation is about severity -->
      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
      <text>
        <reference value="#severity-1"/>
      </text>      <statusCode code="completed"/>
      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value xsi:type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
    </observation>  </entryRelationship></observation>
treetree hl7:templateId
II.EPSOS 1 .. 1 R IHE PCC Problem Entry (EntryAllergyAndIntolerance)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
treetree hl7:templateId
II.EPSOS 1 .. 1 R CCD Alert Observation (EntryAllergyAndIntolerance)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.18
treetree hl7:templateId
II.EPSOS 1 .. 1 R (EntryAllergyAndIntolerance)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.28
treetree hl7:templateId
II.EPSOS 1 .. 1 R (EntryAllergyAndIntolerance)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.6
treetree hl7:id
II.EPSOS 1 .. * M (EntryAllergyAndIntolerance)
treetree hl7:code
CD 1 .. 1 R

The <code> element represents the kind of allergy observation made, to a drug, food or environmental agent, and whether it is an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance). The <code> element of an allergy entry shall be provided, and a code and codeSystem attribute shall be present.

(EntryAllergyAndIntolerance)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.18 epSOSAdverseEventType (DYNAMIC)
treetree hl7:text
ED 1 .. 1 R (EntryAllergyAndIntolerance)
treetree hl7:statusCode
CS 1 .. 1 R (EntryAllergyAndIntolerance)
treeblank treetree @code
1 .. 1 F completed
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.14 (ActStatus)
treetree hl7:effectiveTime
IVL_TS 0 .. 1 R (EntryAllergyAndIntolerance)
treetree hl7:value
CD 0 .. * R

The value element shall be present in a coded or uncoded form. In both cases the type shall be set to xsi:type='CD'. The coded form shall be used to indicate "No known Allergies" (code='160244002' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CD'). In all other cases it shall be in its uncoded form and may contain a <reference> to the <originalText> in the narrative where the allergy is described.

(EntryAllergyAndIntolerance)
treetree hl7:participant
1 .. * R

The substance that causes the allergy or intolerance shall be specified in the <participant> structure.

The <code> element shall be present. It may contain a code and codeSystem attribute to indicate the code for the substance causing the allergy or intolerance. It shall contain a <reference> to the <originalText> in the narrative where the substance is named.

(EntryAllergyAndIntolerance)
  Contains 2.16.840.1.113883.3.1937.777.10.10.134 CDA Participant (Body) (DYNAMIC)
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']]
0 .. * R

An allergy entry can record the reactions that are manifestations of the allergy or intolerance as shown below. It uses a related entry (<entryRelationship>) that indicates the manifestations (typeCode='MFST') the reported allergy or intolerance. These are events that may occur, or have occurred in the past as a reaction to the allergy or intolerance<entryRelationship typeCode='MFST'>

The entry contained with this entry relationship is some sort of problem that is a manifestation of the allergy. It is recorded using the Probl em Entry structure, with the additional template identifier (2.16.840.1.113883.10.20.1.54) indicating that this problem is a reaction.

Note: the 1.3.6.1.4.1.19376.1.5.3.1.4.5 requires that also the template ID '2.16.840.1.113883.10.20.1.28' is included.

(EntryAllergyAndIntolerance)
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC)
treetree hl7:entryRelationship
where
[hl7:observation [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.1' and hl7:templateId/@root='2.16.840.1.113883.10.20.1.55']]
0 .. 1 R

An optional <entryRelationship> element may be present indicating the severity of the problem. If present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1).

The related statement is made about the severity of the condition, concern, or allergy). This observation is recorded inside an <entryRelationship> element occurring in the containing entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the severity of the (surrounding) related entry (e.g., a condition or allergy).

(EntryAllergyAndIntolerance)
  Example <!-- The encompasing condition or allergy observation -->
<observation classCode="COND" moodCode="EVN">
  <!-- ... -->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>
      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
      <text>
        <reference value="#severity-2"/>
      </text>      <statusCode code="completed"/>
      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value xsi:type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>
    </observation>  </entryRelationship>  <!-- ... -->
</observation>
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 Severity (DYNAMIC)