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draft Template  Social History Observation

Id 1.3.6.1.4.1.19376.1.5.3.1.4.13.4 Effective Date 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-113 draft Social History Observations related to: smoke, alcohol and diet draft epSOS Data Set
epsos-dataelement-112 draft Social History Observations draft 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 (Entdotsion)
 
target
epsos-dataelement-112 draft Social History Observations draft 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>
    <low value=" "/>    <high value=" "/>  </effectiveTime>  <value xsi:type=" "/></observation>
hl7:templateId
 II.EPSOS 1 … 1 R (Entdotsion)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:templateId
 II.EPSOS 1 … 1 R (Entdotsion)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.33
hl7:templateId
 II.EPSOS 1 … 1 R (Entdotsion)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13.4
hl7:id
 II.EPSOS 1 … 1 M

Since a Social History Observation is fulfilling the rules of a Simple Observation pattern, each Social History Observation shall have an identifier.

(Entdotsion)
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

(Entdotsion)
 
target
epsos-dataelement-113 draft Social History Observations related to: smoke, alcohol and diet draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.14 epSOSSocialHistory (DYNAMIC)
hl7:text
 ED 1 … 1 M

Since a Social History Observation is fulfilling the rules of a Simple Observation pattern, each Social History Observation shall have a text element.

 (Entdotsion)
hl7:statusCode
 CS 1 … 1 R (Entdotsion)
@code
 CONF 0 … 1 F completed
hl7:effectiveTime
 IVL_TS 1 … 1 R

The effectiveTime element contains a required low and an optional high subelement representing the start date and potential end date of the smoking habit, alcohol consumption or diet.
The low subelement represents the start date of the habit/consumption.
The high subelement represents the date the patient stopped the habit/consumption if applicable. This element shall not be present when observation is still active.

(Entdotsion)
hl7:low
 1 … 1 R The element shall be present. (Entdotsion)
hl7:high
 0 … 1 C The element shall be present for completed or stopped habits/consumptions, and shall not be present otherwise. (Entdotsion)
hl7:repeatNumber
 NP

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

(Entdotsion)
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.
(Entdotsion)
hl7:interpretationCode
 NP

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

(Entdotsion)
hl7:methodCode
 NP

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

(Entdotsion)
hl7:targetSiteCode
 NP

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

(Entdotsion)