Active| Description |
This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below |
| Used by 0 transactions and 0 templates, Uses 1 template | ||||||||
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| Example |
| <observation classCode="OBS" moodCode="EVN" negationInd=" false|true "> <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.7"/> <id root=" " extension=" "/> <code code=" " displayName=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> <text> <reference value=" "/> </text> <statusCode code="completed"/> <effectiveTime> <low value=" "/> <high value=" "/> </effectiveTime> <value xsi:type="CD" code=" " codeSystem=" " displayName=" " codeSystemName=" "> <originalText> <reference value=" "/> </originalText> </value></observation> |
| Item | DT | Card | Conf | Description | Label | |||
|---|---|---|---|---|---|---|---|---|
| hl7:observation | R | eHDS tion | ||||||
| @classCode | cs | 1 … 1 | F | OBS | ||||
| @moodCode | cs | 1 … 1 | F | EVN | ||||
| hl7:templateId | II | 1 … 1 | M | eHDSI Reaction Allergy | eHDStion | |||
| @root | uid | 1 … 1 | F | 1.3.6.1.4.1.12559.11.10.1.3.1.3.28 | ||||
| hl7:id | II | 0 … * | R | eHDStion | ||||
| hl7:code | CD.EPSOS (extensible) | 1 … 1 | R | This element describes the type of condition this observation is referring to. | eHDStion | |||
| CONF |
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| 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. | eHDStion | |||
| hl7:reference | TEL | 1 … 1 | M | eHDStion | ||||
| @value | 1 … 1 | R | Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 | |||||
| hl7:statusCode | CS | 0 … 1 | R | A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'. | eHDStion | |||
| @code | CONF | 0 … 1 | F | completed | ||||
| hl7:effectiveTime | IVL_TS | 0 … 1 | R | The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The <low> and <high> values should be no more precise than known, but as precise as possible. | eHDStion | |||
| Constraint | If the condition is known to be resolved, then the effectiveTime/high would be present. | |||||||
| hl7:low | 1 … 1 | R | The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active | eHDStion | ||||
| hl7:high | 0 … 1 | C | The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK" | eHDStion | ||||
| hl7:value | CD.EPSOS (extensible) | 1 … 1 | R | The <value> is the condition that was found. While the value may be a coded or an un-coded string, the type is always a coded value. If uncoded, it shall contain a <reference> to the <originalText> in the narrative where the reaction is described. | eHDStion | |||
| CONF |
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| hl7:originalText | R | The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus 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. | eHDStion | |||||
| hl7:reference | 0 … 1 | R | The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. | eHDStion | ||||
| Example | <reference value="#eP_as_text"/> | |||||||
| hl7:entryRelationship | 0 … 1 | R | Severity The contained entry describes a subjective assessment of the severity of the condition as evaluated by the clinician Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.8 eHDSI Severity (DYNAMIC) | eHDStion | ||||
| @typeCode | cs | 1 … 1 | F | SUBJ | ||||
| @inversionInd | bl | 1 … 1 | F | true | ||||