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draft Template  Entry Health Status Observation

Id 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 Effective Date 2013‑12‑20
Status draft Draft Version Label
Name EntryHealthStatusObservation Display Name Entry Health Status Observation
Description
A problem observation may reference a health status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The health status observation records information about the current health status of the patient. The example below shows the recording the health status, and is used as the context for the following sections.
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.1.2
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-227 draft Resolution Circumstances draft epSOS Data Set
epsos-dataelement-175 draft Resolution Circumstances draft epSOS Data Set
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="2.16.840.1.113883.10.20.1.51"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.2"/>  <code code="11323-3" displayName="Health Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#hstatus-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 2.16.840.1.113883.10.20.1.51
hl7:templateId
 II 1 … 1 R (Entdotsion)
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.1.2
hl7:code
 CD 1 … 1 R

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

(Entdotsion)
@code
 CONF 0 … 1 F 11323-3
@displayName
 0 … 1 F Health Status
@codeSystem
 0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@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 health 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)
 
target
epsos-dataelement-227 draft Resolution Circumstances draft epSOS Data Set
epsos-dataelement-175 draft Resolution Circumstances draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.30 epSOSResolutionOutcome (DYNAMIC)