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draft Template  Problem

Template 1.3.6.1.4.1.19376.1.5.3.1.4.5 - EntryProblem
Id 1.3.6.1.4.1.19376.1.5.3.1.4.5
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Entry Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5
Open/Closed Open (other than defined elements are allowed)
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.

Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28

Used by / Uses
Used by / Uses 23 templates
Used by Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.12 Containment EntryImmunizations Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23 link SectionImmunizations Section Immunizations 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link epSOS-PS epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link epSOS-HCER epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link epSOS-MRO epSOS-Medication Related Overview 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 Containment EntryProblemConcern Problem Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.6 link SectionActiveProblems Section Active Problems 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8 link SectionHistoryOfPastIllness Section History of Past Illness 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6 Containment EntryAllergyAndIntolerance Allergies And Intolerances 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 link EntryAllergyAndIntoleranceConcern Allergy and Intolerance Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13 link SectionAllergiesAndOtherAdverseReactions Section Allergies and Other Adverse Reactions 2013‑12‑20
Uses Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.1 Containment EntrySeverity DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.1 Containment EntryProblemStatusObservation DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.2 Containment EntryHealthStatusObservation DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment EntryComment DYNAMIC
Relationship Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (DYNAMIC)
Item DT Card Conf Description Label
hl7:observation
R

The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed).

The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations, or which do not allow the negation to be recorded with post-coordinated coded terminology.

(EntryProblem)
treetree @classCode
0 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
  Example <observation classCode="OBS" moodCode="EVN" negationInd=" false|true ">
  <templateId root="2.16.840.1.113883.10.20.1.28"/>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>
  <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>
  <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements identifying the health status of concern -->
  <!-- zero or one <entryRelationship typeCode='REFR' inversionInd='false'> elements containing clinical status -->
  <!-- zero to many <entryRelationship typeCode='REFR' inversionInd='true'> elements containing comments -->
</observation>
treetree hl7:templateId
II 1 .. 1 R (EntryProblem)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
treetree hl7:templateId
II 1 .. 1 R (EntryProblem)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.28
treetree hl7:id
II 1 .. 1 M

The specific observation being recorded must have an identifier (<id>) that shall be provided for tracking purposes. If the source EMR does not or cannot supply an intrinsic identifier, then a GUID shall be provided as the root, with no extension (e.g., <id root='CE1215CD-69EC-4C7B-805F-569233C5E159'/>). While CDA allows for more than one identifier element to be provided, this profile requires that only one be used.

(EntryProblem)
treetree hl7:code
CD 1 .. 1 R

The <code> describes the process of establishing a problem. The code element should be used, as the process of determining the value is important to clinicians (e.g., a diagnosis is a more advanced statement than a symptom). The recommended vocabulary for describing problems is Value set epSOSCodeProb, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.23. This value set is required in epSOS when used within the Problem Concern Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5.2

(EntryProblem)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.23 epSOSCodeProb (DYNAMIC)
treetree 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.

(EntryProblem)
treetree 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'.

(EntryProblem)
treeblank treetree @code
1 .. 1 F completed
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.14 (ActStatus)
treetree hl7:effectiveTime
IVL_TS 0 .. 1 R

The <effectiveTime> of this <observation> is the time interval over which the <observation> is known to be true. The <low> and <high> values should be no more precise than known, but as precise as possible.

While CDA allows for multiple mechanisms to record this time interval (e.g. by low and high values, low and width, high and width, or centre point and width), we are constraining Medical summaries to use only the low/high form.

The <low> value is the earliest point for which the condition is known to have existed.

The <high> value, when present, indicates the time at which the observation was no longer known to be true. Thus, the implication is made that if the <high> value is specified, that the observation was no longer seen after this time, and it thus represents the date of resolution of the problem.

Similarly, the <low> value may seem to represent onset of the problem. Neither of these statements is necessarily precise, as the <low> and <high> values may represent only an approximation of the true onset and resolution (respectively) times. For example, it may be the case that onset occurred prior to the <low> value, but no observation may have been possible before that time to discern whether the condition existed prior to that time.

The <low> value should normally be present. There are exceptions, such as for the case where the patient may be able to report that they had chicken pox, but are unsure when. In this case, the <effectiveTime> element shall have a <low> element with a nullFlavor attribute set to 'UNK'. The <high> value need not be present when the observation is about a state of the patient that is unlikely to change (e.g., the diagnosis of an incurable disease).

(EntryProblem)
treetree hl7:value
CD 1 .. * M

The <value> is the condition that was found. This element is required. While the value may be a coded or an un-coded string, the type is always a coded value (xsi:type='CD'). If coded, the code and codeSystem attributes shall be present.

The Value Set used is epSOSIllnessesandDisorders, with the OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.5.

The value set to be used when this template is specialized for describing adverse reaction is epSOSReactionAllergy.

In cases where information about a problem or allergy is unknown or where there are no problems or allergies, an entry shall use codes from epSOSUnknownInformation, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.17.

(EntryProblem)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.11 epSOSReactionAllergy (DYNAMIC)
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.5 epSOSIllnessesandDisorders (DYNAMIC)
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.17 epSOSUnknownInformation (DYNAMIC)
treeblank treetree 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.

(EntryProblem)
treeblank treeblank treetree 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. (EntryProblem)
  Example <reference value="#eP_as_text"/>
treetree hl7:entryRelationship
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']]
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 severity codes to be used are epSOSSeverity, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.13.

This shall be represented with the <entryRelationship> element. The typeCode shall be ‘SUBJ’ and inversionInd shall be ‘true’.

(EntryProblem)
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 Severity (DYNAMIC)
treetree hl7:entryRelationship
where
[hl7:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.1.57' and hl7:templateId/@root='2.16.840.1.113883.10.20.1.50' and hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1']]
0 .. 1 R

An optional <entryRelationship> may be present indicating the clinical status of the problem, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the Problem Status Observation template (1.3.6.1.4.1.19376.1.5.3.1.4.1.1). The value set to be used is epSOSstatusCode, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.15.

This shall be represented with the <entryRelationship> element. The typeCode shall be ‘REFR’ and inversionInd shall be ‘false’.

(EntryProblem)
treeblank treetree @typeCode
1 .. 1 F REFR
treeblank treetree @inversionInd
0 .. 1 F false
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 Entry Problem Status Observation (DYNAMIC)
treetree hl7:entryRelationship
where
[hl7:observation [hl7:templateId/@root='2.16.840.1.113883.10.20.1.51' and hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2']]
0 .. 1 R

An optional <entryRelationship> may be present referencing the health status of the patient, e.g., resolved, in remission, active. When present, this <entryRelationship> element shall contain a clinical status observation conforming to the template (1.3.6.1.4.1.19376.1.5.3.1.4.1.2). ). The value set to be used is epSOSResolutionOutcome, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.30. The typeCode shall be ‘REFR’ and inversionInd shall be ‘false’.

This shall be represented with the <entryRelationship> element.

(EntryProblem)
treeblank treetree @typeCode
1 .. 1 F REFR
treeblank treetree @inversionInd
0 .. 1 F false
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 Entry Health Status Observation (DYNAMIC)
treetree hl7:entryRelationship
where
[hl7:act [hl7:templateId/@root='2.16.840.1.113883.10.20.1.40' and hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.2']]
0 .. 1 R

One or more optional <entryRelationship> elements may be present providing an additional comments (annotations) for the condition. When present, this <entryRelationship> element shall contain a comment observation conforming to the entry template (1.3.6.1.4.1.19376.1.5.3.1.4.2). The typeCode shall be ‘SUBJ’ and inversionInd shall be ‘true’.

This shall be represented with the <entryRelationship> element.

(EntryProblem)
treeblank treetree @typeCode
1 .. 1 F SUBJ
treeblank treetree @inversionInd
1 .. 1 F true
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 Comment (DYNAMIC)