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ref Template  Allergies And Intolerances

Id 1.3.6.1.4.1.19376.1.5.3.1.4.6 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name EntryAllergyAndIntolerance Display Name Allergies And Intolerances
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

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.6
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 3 concepts
Id Name Data Set
epsos-dataelement-68 Allergy description epSOS Data Set
epsos-dataelement-69 Allergy code epSOS Data Set
epsos-dataelement-70 Onset Date epSOS Data Set
Used by / Uses
Used by 0 transactions and 5 templates, Uses 3 templates
Used by as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 Containment draft Allergy and Intolerance Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13 link draft Section Allergies and Other Adverse Reactions 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
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.134 Containment draft CDA Participant (Body) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment draft Problem DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1 Containment draft Severity 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)
Example
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>
notice There are open issues with this item:
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.

(Entdotsnce)
@classCode
 cs 1 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
@negationInd
 bl 0 … 1  
hl7:templateId
 II.EPSOS 1 … 1 R IHE PCC Problem Entry (Entdotsnce)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
 II.EPSOS 1 … 1 R CCD Alert Observation (Entdotsnce)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.18
hl7:templateId
 II.EPSOS 1 … 1 R (Entdotsnce)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.28
hl7:templateId
 II.EPSOS 1 … 1 R (Entdotsnce)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.6
hl7:id
 II.EPSOS 0 … * R (Entdotsnce)
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.

(Entdotsnce)
 
target epsos-dataelement-69 Allergy code epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.18 epSOSAdverseEventType (DYNAMIC)
hl7:text
 ED 1 … 1 R (Entdotsnce)
 
target epsos-dataelement-68 Allergy description epSOS Data Set
hl7:reference
 TEL 1 … 1 M (Entdotsnce)
@value
 1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 CS 1 … 1 R (Entdotsnce)
@code
 CONF 0 … 1 F completed
hl7:effectiveTime
 IVL_TS 0 … 1 R (Entdotsnce)
 
target epsos-dataelement-70 Onset Date epSOS Data Set
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 CT'). 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.

(Entdotsnce)
hl7:participant
 0 … * C

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.


Contains 2.16.840.1.113883.3.1937.777.11.10.134 CDA Participant (Body) (DYNAMIC) 		(Entdotsnce)
  Constraint Conditional: Omit if Observation.value is SNOMED-CT 160244002 No known Allergies
hl7:entryRelationship
 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.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC) 		(Entdotsnce)
treeblank 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']]]
hl7:entryRelationship
 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).


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 Severity (DYNAMIC) 		(Entdotsnce)
treeblank 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']]]
  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>