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draft Template  Entry Problem Status Observation

Id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 Effective Date 2013‑12‑20
Status draft Draft Version Label
Name EntryProblemStatusObservation Display Name Entry Problem Status Observation
Description

(CCD) Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

This CCD models a problem status observation as a separate observation from the problem, allergy or medication observation. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify problem status in the coded condition observation, and a separate clinical status observation is no longer necessary. The use of qualifiers in the problem observation is not precluded by this specification or by CCD. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that problem status information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 12 templates, Uses 0 templates
Used by as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment draft Problem 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.12 link draft Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23 link draft Section Immunizations 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
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 link draft Problem Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.6 link draft Section Active Problems 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8 link draft Section History of Past Illness 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6 link draft Allergies And Intolerances 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 link 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
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.57"/>  <templateId root="2.16.840.1.113883.10.20.1.50"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.1"/>  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#cstatus-2"/>  </text>  <statusCode code="completed"/>  <value xsi:type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></observation>
notice There is an open issue with this item:
Item DT Card Conf Description Label
hl7:observation
 (Entdotsion)
@classCode
 0 … 1 F OBS
@moodCode
 0 … 1 F EVN
hl7:templateId
 II 1 … 1 R (Entdotsion)
@root
 1 … 1 F 2.16.840.1.113883.10.20.1.57
hl7:templateId
 II 1 … 1 R (Entdotsion)
@root
 1 … 1 F 2.16.840.1.113883.10.20.1.50
hl7:templateId
 II 1 … 1 R (Entdotsion)
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
hl7:code
 CD 1 … 1 R

This observation is of clinical status, as indicated by the <code> element. This element must be present.

(Entdotsion)
@code
 CONF 0 … 1 F 33999-4
@codeSystem
 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@displayName
 0 … 1 F Status
@codeSystemName
 0 … 1 F LOINC
hl7:text
 ED 1 … 1 M

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

(Entdotsion)
hl7:reference
 TEL 1 … 1 M (Entdotsion)
@value
 1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 CS 1 … 1 M

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

(Entdotsion)
@code
 CONF 1 … 1 F completed
hl7:value
 CE.EPSOS 1 … 1 R The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT. (Entdotsion)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.15 epSOSStatusCode (DYNAMIC)