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ref Template  Social History Observation

Id 1.3.6.1.4.1.19376.1.5.3.1.4.13.4 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name EntrySocialHistoryObservation Display Name Social History Observation
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

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.13.4
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 2 concepts
Id Name Data Set
epsos-dataelement-112 Social History Observations epSOS Data Set
epsos-dataelement-113 Social History Observations related to: smoke, alcohol and diet epSOS Data Set
Used by / Uses
Used by 0 transactions and 4 templates, Uses 0 templates
Used by as Name Version
1.3.6.1.4.1.19376.1.5.3.1.3.16.1 Containment draft Section Coded Social History 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link draft epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link draft epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link draft epSOS-Medication Related Overview 2013‑12‑20
Relationship Specialization: template 2.16.840.1.113883.10.20.1.33 (DYNAMIC)
notice There are open issues with this item:
Item DT Card Conf Description Label
hl7:observation
 R (Ent…ion)
  target
epsos-dataelement-112 Social History Observations epSOS Data Set
  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=" "/>  <value xsi:type=" "/></observation>
hl7:templateId
 II.EPSOS 1 … 1 R (Ent…ion)
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:templateId
 II.EPSOS 1 … 1 R (Ent…ion)
@root
 1 … 1 F 2.16.840.1.113883.10.20.1.33
hl7:templateId
 II.EPSOS 1 … 1 R (Ent…ion)
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13.4
hl7:code
 CD 1 … 1 M

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

(Ent…ion)
  target
epsos-dataelement-113 Social History Observations related to: smoke, alcohol and diet epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.14 epSOSSocialHistory (DYNAMIC)
hl7:statusCode
 CS 1 … 1 R (Ent…ion)
@code
 CONF 0 … 1 F completed
hl7:repeatNumber
 NP

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

(Ent…ion)
hl7:value
 ANY 1 … * R

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. 

                                    
                                 		
                                 (Ent…ion)
                              

                              

                                  
                                 target
                                 
                                    

                                       

                                          epsos-dataelement-113
                                          Social History Observations related to: smoke, alcohol and diet
                                          epSOS Data Set 
                                       

                                    

                                 		
                              

                              

                                 hl7:interpretationCode

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

                                    
                                 		
                                 (Ent…ion)
                              

                              

                                 hl7:methodCode

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

                                    
                                 		
                                 (Ent…ion)
                              

                              

                                 hl7:targetSiteCode

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

                                    
                                 		
                                 (Ent…ion)