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ref Template  Problem Concern

Id 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name EntryProblemConcern Display Name Problem Concern
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.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 7 concepts
Id Name Data Set
epsos-dataelement-222 Problem/Diagnosis epSOS Data Set
epsos-dataelement-306 Problem Status epSOS Data Set
epsos-dataelement-223 Problem/diagnosis Description epSOS Data Set
epsos-dataelement-305 Problem Status epSOS Data Set
epsos-dataelement-84 Problem/diagnosis Description epSOS Data Set
epsos-dataelement-86 Onset Time epSOS Data Set
epsos-dataelement-174 End date epSOS Data Set
Used by / Uses
Used by 0 transactions and 5 templates, Uses 1 template
Used by as Name Version
1.3.6.1.4.1.19376.1.5.3.1.3.6 Containment draft Section Active Problems 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
1.3.6.1.4.1.19376.1.5.3.1.3.8 Containment draft Section History of Past Illness 2013‑12‑20
Uses as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment draft Problem DYNAMIC
Example
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>
Item DT Card Conf Description Label
hl7:act
 R (Entdotsern)
 
target epsos-dataelement-222 Problem/Diagnosis epSOS Data Set
@classCode
 cs 1 … 1 F ACT
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M (Entdotsern)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.27
hl7:templateId
 II 1 … 1 M (Entdotsern)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5.1
hl7:templateId
 II 1 … 1 M (Entdotsern)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
hl7:id
 II 1 … * R (Entdotsern)
hl7:code
 CD 1 … 1 R Fixed nullFlavor='NA' (Entdotsern)
hl7:text
 ED 0 … 1 R (Entdotsern)
 
target epsos-dataelement-223 Problem/diagnosis Description epSOS Data Set
  epsos-dataelement-84 Problem/diagnosis Description epSOS Data Set
hl7:reference
 TEL 1 … 1 M (Entdotsern)
@value
 1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 CS 0 … 1 R One of: active|suspended|aborted|completed (Entdotsern)
 
target epsos-dataelement-306 Problem Status epSOS Data Set
  epsos-dataelement-305 Problem Status epSOS Data Set
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.777.11.11.2 ActStatusActiveAbortedSuspendedCompleted (DYNAMIC)
hl7:effectiveTime
 IVL_TS 0 … 1 R (Entdotsern)
hl7:low
 1 … 1 R The <low> element shall be present. (Entdotsern)
 
target epsos-dataelement-86 Onset Time epSOS Data Set
hl7:high
 0 … 1 C The <high> element shall be present for concerns in the completed or aborted state, and shall not be present otherwise. (Entdotsern)
 
target epsos-dataelement-174 End date epSOS Data Set
hl7:entryRelationship
 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.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC) 		(Entdotsern)
treeblank where [@typeCode='SUBJ'] [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']]]
@typeCode
 cs 1 … 1 F SUBJ
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
@typeCode
 cs 1 … 1 F REFR
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
@classCode
 cs 0 … 1 F OBS CONF‑526
  The value for “Observation / @classCode” in a source of information observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
@moodCode
 cs 0 … 1 F EVN CONF‑527
  The value for “Observation / @moodCode” in a source of information observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
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
@code
 CONF 0 … 1 F 48766-0
@codeSystem
 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@displayName
 0 … 1 F Information source
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
@code
 CONF 0 … 1 F completed
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