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active Template  eHDSI Problem Concern

Id 1.3.6.1.4.1.12559.11.10.1.3.1.3.15 Effective Date 2020‑09‑03 12:59:44
Other versions this id:
Status active Active Version Label
Name eHDSIProblemConcern Display Name eHDSI Problem Concern
Description

This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused on a problem. Elements shown in the example below in gray are explained in the Concern Entry.

The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.2.

Context Parent nodes of template element with id 1.3.6.1.4.1.12559.11.10.1.3.1.3.15
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 7 concepts
Id Name Data Set
epsos-dataelement-84 draft Problem/diagnosis Description draft epSOS Data Set
epsos-dataelement-305 draft Problem Status draft epSOS Data Set
epsos-dataelement-222 draft Problem/Diagnosis draft epSOS Data Set
epsos-dataelement-306 draft Problem Status draft epSOS Data Set
epsos-dataelement-223 draft Problem/diagnosis Description draft epSOS Data Set
epsos-dataelement-174 draft End date draft epSOS Data Set
epsos-dataelement-86 draft Onset Time draft epSOS Data Set
Used by / Uses
Used by 1 transaction and 3 templates, Uses 1 template
Used by as Name Version
epsos-transactions-12 Transaction draft Return PS of country A 2012‑05‑02
1.3.6.1.4.1.12559.11.10.1.3.1.2.10 Containment active eHDSI History Of Past Illness 2020‑09‑02 14:07:10
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link active eHDSI Patient Summary 2020‑09‑02 10:19:44
1.3.6.1.4.1.12559.11.10.1.3.1.2.9 Containment active eHDSI Active Problems 2020‑09‑02 13:55:25
Uses as Name Version
1.3.6.1.4.1.12559.11.10.1.3.1.3.7 Containment active eHDSI Problem DYNAMIC
Relationship Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5.2 eHDSI Problem Concern (DYNAMIC)
Example
Example
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.15"/>  <templateId root="2.16.840.1.113883.10.20.1.27"/>  <id root=" " extension=" "/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>  <statusCode code="active|suspended|aborted|completed"/>  <effectiveTime>
    <low value=" "/>    <high value=" "/>  </effectiveTime>
  <!-- 1..* entry relationships identifying problems of concern -->
  <entryRelationship type="SUBJ">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.7"/>      <!-- ... -->
    </observation>
  </entryRelationship>
  <!-- optional entry relationship providing more information about the concern -->
  <entryRelationship type="REFR"/></act>
Example
No information available
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.15"/>  <templateId root="2.16.840.1.113883.10.20.1.27"/>  <id root="2.999.4.1" extension="__example only__"/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>  <statusCode code="active"/>  <entryRelationship inversionInd="false" typeCode="SUBJ">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.7"/>      <id root="2.999.4.1.1" extension="__example only__"/>      <code code="404684003" codeSystem="2.16.840.1.113883.6.96" displayName="Clinical finding" codeSystemName="SNOMED CT"/>      <text>
        <reference value="#Problems_None"/>      </text>
      <value code="no-problem-info" displayName="No information about problems" codeSystem="2.16.840.1.113883.5.1150.1" codeSystemName="IPS Absent and Unknown Data" xsi:type="CD"/>    </observation>
  </entryRelationship>
</act>
Example
Known absence
<act classCode="ACT" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.15"/>  <templateId root="2.16.840.1.113883.10.20.1.27"/>  <id root="2.999.4.1" extension="__example only__"/>  <code code="CONC" codeSystem="2.16.840.1.113883.5.6"/>  <statusCode code="active"/>  <entryRelationship inversionInd="false" typeCode="SUBJ">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.7"/>      <id root="2.999.4.1.1" extension="__example only__"/>      <code code="404684003" codeSystem="2.16.840.1.113883.6.96" displayName="Clinical finding" codeSystemName="SNOMED CT"/>      <text>
        <reference value="#Problems_None"/>      </text>
      <value code="no-known-problems" displayName="No known problems" codeSystem="2.16.840.1.113883.5.1150.1" codeSystemName="IPS Absent and Unknown Data" xsi:type="CD"/>    </observation>
  </entryRelationship>
</act>
Item DT Card Conf Description Label
hl7:act
R (eHDdotsern)
 
target
epsos-dataelement-222 draft Problem/Diagnosis draft epSOS Data Set
@classCode
cs 1 … 1 F ACT
@moodCode
cs 1 … 1 F EVN
hl7:templateId
II 1 … 1 M

eHDSI Problem Concern

(eHDdotsern)
@root
uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.3.15
hl7:templateId
II 0 … 1 R IHE Concern Entry (IHE PCC) (eHDdotsern)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5.1
hl7:templateId
II 0 … 1 R IHE Problem Concern Entry (IHE PCC) (eHDdotsern)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
hl7:templateId
II 1 … 1 M Problem act (CCD) (eHDdotsern)
@root
uid 1 … 1 F 2.16.840.1.113883.10.20.1.27
hl7:id
II 1 … * R (eHDdotsern)
hl7:code
CD 1 … 1 M (eHDdotsern)
@code
CONF 1 … 1 F CONC
@codeSystem
1 … 1 F 2.16.840.1.113883.5.6 (ActClass)
hl7:text
ED 0 … 1 R (eHDdotsern)
 
target
epsos-dataelement-84 draft Problem/diagnosis Description draft epSOS Data Set
epsos-dataelement-223 draft Problem/diagnosis Description draft epSOS Data Set
hl7:reference
TEL 1 … 1 M (eHDdotsern)
@value
1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS 0 … 1 R One of: active|suspended|aborted|completed (eHDdotsern)
 
target
epsos-dataelement-305 draft Problem Status draft epSOS Data Set
epsos-dataelement-306 draft Problem Status draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.777.11.11.2 ActStatusActiveAbortedSuspendedCompleted (DYNAMIC)
hl7:effectiveTime
IVL_TS 0 … 1 R (eHDdotsern)
hl7:low
1 … 1 R Problem onset date.
The element shall be present.
(eHDdotsern)
 
target
epsos-dataelement-86 draft Onset Time draft epSOS Data Set
hl7:high
0 … 1 C Problem end date.
The element shall be present for concerns in the completed or aborted state, and shall not be present otherwise.
(eHDdotsern)
 
target
epsos-dataelement-174 draft End date draft epSOS Data Set
hl7:entryRelationship
1 … * R

This entry shall contain one or more problem entries that conform to the Problem Entry template (OID: 1.3.6.1.4.1.12559.11.10.1.3.1.3.7). For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

Note: every Problem Entry used in this section to identify problem of concern MAY have an <entryRelationship> that will indicate the severity of the problem, conforming to the eHDSI Severity template (OID: 1.3.6.1.4.1.12559.11.10.1.3.1.3.8). The severity codes to be used are eHDSISeverity, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.13.


Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.7 eHDSI Problem (DYNAMIC)
(eHDdotsern)
@typeCode
cs 1 … 1 F SUBJ
hl7:entryRelationship
0 … * R optional entry relationship providing more information about the concern. A source of information observation SHALL be the target of an entryRelationship whose value for “entryRelationship / @typeCode” SHALL be “REFR” “Refers to” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC. A source of information observation SHALL be represented with Observation. CONF‑524 / CONF‑525
@typeCode
cs 1 … 1 F REFR
hl7:observation
ASTM CCR requires that all data objects have a stated source (or state explicitly that the source is unknown) so that any data within the summary can be validated. The source of data may be a person, organization, reference to some other data object, etc. CONF‑524 / CONF‑525
@classCode
cs 0 … 1 F OBS CONF‑526
  The value for “Observation / @classCode” in a source of information observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
@moodCode
cs 0 … 1 F EVN CONF‑527
  The value for “Observation / @moodCode” in a source of information observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
hl7:code
CD 1 … 1 R A source of information observation SHALL contain exactly one Observation / code. The value for “Observation / code” in a source of information observation SHALL be “48766-0” “Information source” 2.16.840.1.113883.6.1 LOINC STATIC. CONF‑530 / CONF‑531
@code
CONF 0 … 1 F 48766-0
@codeSystem
0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@displayName
0 … 1 F Information source
hl7:statusCode
1 … 1 R A source of information observation SHALL contain exactly one Observation / statusCode. The value for “Observation / statusCode” in a source of information observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC. CONF‑528 / CONF‑529
@code
CONF 0 … 1 F completed
hl7:value
1 … 1 M A source of information observation SHALL contain exactly one Observation / value. The absence of a known source of information SHALL be explicity asserted by valuing Observation / value in a source of information observation with the text string “Unknown”. CONF‑532 / CONF‑533