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active Template  eHDSI Allergies And Intolerances

Id 1.3.6.1.4.1.19376.1.5.3.1.4.6 Effective Date 2020‑04‑16 12:29:45
Other versions this id:
Status active Active Version Label
Name eHDSIAllergiesAndIntolerances Display Name eHDSI Allergies And Intolerances
Description

Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA <observation> element, with classCode='OBS'. They follow the same pattern as the problem entry, with exceptions noted below.

Parent Template

This is a specialization of the IHE PCC Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5 and of the CCD alert observation template 2.16.840.1.113883.10.20.1.18

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.6
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 5 concepts
Id Name Data Set
epsos-dataelement-70 draft Onset Date draft epSOS Data Set
epsos-dataelement-209 draft Agent Code draft epSOS Data Set
epsos-dataelement-208 draft Agent description draft epSOS Data Set
epsos-dataelement-68 draft Allergy description draft epSOS Data Set
epsos-dataelement-69 draft Allergy code draft epSOS Data Set
Used by / Uses
Used by 3 transactions and 14 templates, Uses 2 templates
Used by as Name Version
epsos-transactions-23 Transaction draft Return MRO 2013‑11‑02
epsos-transactions-21 Transaction draft Send HCER to country A 2013‑11‑02
epsos-transactions-12 Transaction draft Return PS of country A 2012‑05‑02
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 Containment active eHDSI Allergy And Intolerance Concern 2020‑04‑16 12:30:31
1.3.6.1.4.1.19376.1.5.3.1.3.13 link active eHDSI Allergies and Other Adverse Reactions 2020‑04‑16 11:58:56
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link active eHDSI Patient Summary 2020‑04‑14 13:03:47
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired epSOS-Patient Summary 2018‑11‑14 10:53:50
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link retired epSOS-Health Care Encounter Report 2018‑11‑14 09:02:41
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link retired epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link retired epSOS-Medication Related Overview 2018‑11‑14 09:03:13
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link retired epSOS-Medication Related Overview 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13 link retired Section Allergies and Other Adverse Reactions 2019‑04‑05 14:39:34
1.3.6.1.4.1.19376.1.5.3.1.3.13 link retired Section Allergies and Other Adverse Reactions 2019‑04‑05 14:39:26
1.3.6.1.4.1.19376.1.5.3.1.3.13 link retired Section Allergies and Other Adverse Reactions 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 Containment retired Allergy and Intolerance Concern 2019‑04‑08 13:59:03
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 Containment retired Allergy and Intolerance Concern 2013‑12‑20
Uses as Name Version
1.3.6.1.4.1.12559.11.10.1.3.1.3.7 Containment active eHDSI Problem DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1 Containment active eHDSI Severity DYNAMIC
Relationship Version: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 Allergies And Intolerances (2019‑02‑11 15:08:49)
Version: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 Allergies And Intolerances (2013‑12‑20)
Specialization: template 2.16.840.1.113883.10.20.1.18 (DYNAMIC)
ref
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Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (DYNAMIC)
ref
?
Example
Example
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="2.16.840.1.113883.10.20.1.18"/>  <templateId root="2.16.840.1.113883.10.20.1.28"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>  <id root=" " extension=" "/>  <!-- This is the code that shows what kind of allergy or intolerance derived from the eHDSIAdverseEventType Value Set-->
  <code code="" codeSystem="2.16.840.1.113883.6.96"/>  <text>
    <reference value=" "/>  </text>
  <statusCode code="completed"/>  <effectiveTime>
    <low value=" "/>    <high value=" "/>  </effectiveTime>
  <!-- value element is present only to indicate no known allergies, in all other cases is used for referenicng text in the narrative -->
  <value type="CD"/>  <!-- This is the allergen - the substance that caused the allergy -->
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code=" " codeSystem=" ">
          <originalText>
            <reference value="#substance"/>          </originalText>
        </code>
        <name/>      </playingEntity>
    </participantRole>
  </participant>
  <!-- This is how the allergy manifests itself -->
  <entryRelationship typeCode="MFST">
    <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6.1"/>    <!-- a problem entry -->
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.54"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>      <!-- The code tells us that the observation is a symptom -->
      <code code="418799008" codeSystem="2.16.840.1.113883.6.96" displayName="Finding reported by subject or history provider" codeSystemName="SNOMED CT"/>      <text>
        <reference value="#manifest-1"/>      </text>
      <statusCode code="completed"/>      <!-- The value tells us what the symptom (i.e. allergy manifestation) is -->
      <!-- This is where anaphylaxy or angiooedema will be coded -->
      <value type="CD" code=" " codeSystem=" " displayName=" " codeSystemName=" "/>    </observation>
  </entryRelationship>
  <!-- This is how the severity of the allergy is described (Optional)-->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>      <!-- This code is from HL7 and indicates that the observation is about severity -->
      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>      <text>
        <reference value="#severity-1"/>      </text>
      <statusCode code="completed"/>      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>    </observation>
  </entryRelationship>
</observation>
Item DT Card Conf Description Label
hl7:observation
R

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.6, and is a subtype of the Problem Entry, and so must also conform to the rules of the problem entry, which has the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5. These elements are required and shall be recorded exactly as shown above.

Note: the 1.3.6.1.4.1.19376.1.5.3.1.4.5 requires that also the template ID '2.16.840.1.113883.10.20.1.28' is included.

(eHDdotsces)
@classCode
cs 1 … 1 F OBS
@moodCode
cs 1 … 1 F EVN
@negationInd
bl 0 … 1  
hl7:templateId
II.EPSOS 1 … 1 R IHE PCC Problem Entry (eHDdotsces)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II.EPSOS 1 … 1 R CCD Alert Observation (eHDdotsces)
@root
uid 1 … 1 F 2.16.840.1.113883.10.20.1.18
hl7:templateId
II.EPSOS 1 … 1 R (eHDdotsces)
@root
uid 1 … 1 F 2.16.840.1.113883.10.20.1.28
hl7:templateId
II.EPSOS 1 … 1 R (eHDdotsces)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.6
hl7:id
II.EPSOS 0 … * R (eHDdotsces)
hl7:code
CD 1 … 1 R

The <code> element represents the kind of allergy observation made, to a drug, food or environmental agent, and whether it is an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance). The <code> element of an allergy entry shall be provided, and a code and codeSystem attribute shall be present.

(eHDdotsces)
 
target
epsos-dataelement-69 draft Allergy code draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.18 eHDSIAdverseEventType (DYNAMIC)
hl7:text
ED 1 … 1 R (eHDdotsces)
 
target
epsos-dataelement-68 draft Allergy description draft epSOS Data Set
hl7:reference
TEL 1 … 1 M (eHDdotsces)
@value
1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS 1 … 1 R (eHDdotsces)
@code
CONF 0 … 1 F completed
hl7:effectiveTime
IVL_TS 0 … 1 R (eHDdotsces)
 
target
epsos-dataelement-70 draft Onset Date draft epSOS Data Set
hl7:value
CD 0 … * R

The value element shall be present in a coded or uncoded form. In both cases the type shall be set to xsi:type='CD'.
In the case of no information or known absence of allergies, one of the following codes from the eHDSIAbsentOrUnknownAllergy value set has to be used:

If one of these values is used, the participant used for indicating the allergy agent shall be omitted.
In all other cases it shall be in its uncoded form and may contain a <reference> to the <originalText> in the narrative where the allergy is described.

(eHDdotsces)
hl7:participant
0 … 1 C

The substance that causes the allergy or intolerance should be specified in the <participant> structure.
This is the preferred way an allergy is supposed to be expressed.
However it is recognized that in some contexts a controlled vocabulary is used for describing the allergy to a substance; or for asserting known absence or unavailability of information.
In this case the <participant> structure shall be omitted.
The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT" for all agents, manufactured or not.

(eHDdotsces)
@typeCode
cs 1 … 1 F CSM
  Constraint IF the observation/value element is present and valued with a code indicating the known absence/no information on allergies THEN the observation/participant element used to describe the agent SHALL be omitted.
hl7:participantRole
1 … 1 R (eHDdotsces)
@classCode
cs 1 … 1 F MANU
hl7:playingEntity
1 … 1 R (eHDdotsces)
@classCode
cs 1 … 1 F MMAT
hl7:code
CD.EPSOS 1 … 1 R Code for the substance causing the allergy or intolerance. (eHDdotsces)
 
target
epsos-dataelement-209 draft Agent Code draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.19 eHDSIAllergenNoDrug (DYNAMIC)
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.24 eHDSIActiveIngredient (DYNAMIC)
hl7:name
PN 0 … * R Name for the substance causing the allergy or intolerance. (eHDdotsces)
 
target
epsos-dataelement-208 draft Agent description draft epSOS Data Set
hl7:entryRelationship
0 … * R

An allergy entry can record the reactions that are manifestations of the allergy or intolerance as shown below. It uses a related entry (<entryRelationship>) that indicates the manifestations (typeCode='MFST') the reported allergy or intolerance. These are events that may occur, or have occurred in the past as a reaction to the allergy or intolerance<entryRelationship typeCode='MFST'>

The entry contained with this entry relationship is some sort of problem that is a manifestation of the allergy. It is recorded using the Probl em Entry structure.


Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.7 eHDSI Problem (DYNAMIC)
(eHDdotsces)
@typeCode
cs 1 … 1 F MFST
hl7:entryRelationship
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 related statement is made about the severity of the condition, concern, or allergy). This observation is recorded inside an <entryRelationship> element occurring in the containing entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the severity of the (surrounding) related entry (e.g., a condition or allergy).


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 eHDSI Severity (DYNAMIC)
(eHDdotsces)
@typeCode
cs 1 … 1 F SUBJ
  Example <!-- The encompasing condition or allergy observation -->
<observation classCode="COND" moodCode="EVN">
  <!-- ... -->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>      <text>
        <reference value="#severity-2"/>      </text>
      <statusCode code="completed"/>      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>    </observation>
  </entryRelationship>
  <!-- ... -->
</observation>