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active Template  eHDSI Problem Status Observation

Id 1.3.6.1.4.1.12559.11.10.1.3.1.3.9 Effective Date 2020‑09‑03 07:57:37
Other versions this id:
Status active Active Version Label
Name eHDSIProblemStatusObservation Display Name eHDSI Problem Status Observation
Description

(CCD) Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

This CCD models a problem status observation as a separate observation from the problem, allergy or medication observation. While this model is different from work presently underway by various organizations (i.e., SNOMED, HL7, TermInfo), it is not wholly incompatible with that work. In that work, qualifiers may be used to identify problem status in the coded condition observation, and a separate clinical status observation is no longer necessary. The use of qualifiers in the problem observation is not precluded by this specification or by CCD. However, to support semantic interoperability between EMR systems using different vocabularies, this specification does require that problem status information also be provided in a separate observation. This ensures that all EMR systems have equal access to the information, regardless of the vocabularies they support.

Context Parent nodes of template element with id 1.3.6.1.4.1.12559.11.10.1.3.1.3.9
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 3 transactions and 37 templates, Uses 0 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
1.3.6.1.4.1.12559.11.10.1.3.1.3.7 Containment active eHDSI Problem 2020‑09‑02 15:24:28
1.3.6.1.4.1.12559.11.10.1.3.1.3.15 link active eHDSI Problem Concern 2020‑09‑03 12:59:44
1.3.6.1.4.1.12559.11.10.1.3.1.2.10 link 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 link active eHDSI Active Problems 2020‑09‑02 13:55:25
1.3.6.1.4.1.12559.11.10.1.3.1.3.17 link active eHDSI Allergies And Intolerances 2020‑09‑02 15:26:02
1.3.6.1.4.1.12559.11.10.1.3.1.3.16 link active eHDSI Allergy And Intolerance Concern 2020‑09‑03 13:10:28
1.3.6.1.4.1.12559.11.10.1.3.1.2.12 link active eHDSI Allergies and Other Adverse Reactions 2020‑09‑02 14:34:55
1.3.6.1.4.1.12559.11.10.1.3.1.3.19 link active eHDSI Immunization 2020‑09‑03 12:13:36
1.3.6.1.4.1.12559.11.10.1.3.1.2.15 link active eHDSI Immunizations 2020‑09‑02 14:55:50
1.3.6.1.4.1.19376.1.5.3.1.4.12 link retired eHDSI Immunizations 2020‑04‑16 13:06:27
1.3.6.1.4.1.19376.1.5.3.1.3.23 link retired eHDSI Immunizations 2020‑04‑16 12:18:30
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired 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
1.3.6.1.4.1.19376.1.5.3.1.3.23 link retired Section Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.12 link retired Immunizations 2019‑05‑13 12:25:08
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 link retired eHDSI Problem Concern 2020‑04‑16 13:26:35
1.3.6.1.4.1.19376.1.5.3.1.3.6 link retired eHDSI Active Problems 2020‑04‑16 11:58:12
1.3.6.1.4.1.19376.1.5.3.1.3.6 link retired Section Active Problems 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8 link retired eHDSI History Of Past Illness 2020‑04‑16 12:17:41
1.3.6.1.4.1.19376.1.5.3.1.3.8 link retired Section History of Past Illness 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 link retired Problem Concern 2019‑03‑12 15:36:45
1.3.6.1.4.1.19376.1.5.3.1.4.6 link retired eHDSI Allergies And Intolerances 2020‑04‑16 12:29:45
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 link retired 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 retired eHDSI Allergies and Other Adverse Reactions 2020‑04‑16 11:58:56
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 link 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 link retired Allergy and Intolerance Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6 link retired Allergies And Intolerances 2019‑11‑15 08:41:37
1.3.6.1.4.1.19376.1.5.3.1.4.6 link retired Allergies And Intolerances 2019‑02‑11 15:08:49
Relationship Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 eHDSI Problem Status Observation (DYNAMIC)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.9"/>  <templateId root="2.16.840.1.113883.10.20.1.57"/>  <templateId root="2.16.840.1.113883.10.20.1.50"/>  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#cstatus-2"/>  </text>  <statusCode code="completed"/>  <value type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></observation>
Item DT Card Conf Description Label
hl7:observation
 		(eHDdotsion)
@classCode
 		cs 0 … 1 F OBS
@moodCode
 		cs 0 … 1 F EVN
hl7:templateId
 		II 1 … 1 R eHDSI Problem Status Observation (eHDdotsion)
@root
 		uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.3.9
hl7:templateId
 		II 0 … 1 R IHE Problem Status Observation (IHE PCC) (eHDdotsion)
@root
 		uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
hl7:templateId
 		II 1 … 1 R Status observation (CCD) (eHDdotsion)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.1.57
hl7:templateId
 		II 1 … 1 R Problem status observation (CCD) (eHDdotsion)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.1.50
hl7:code
 		CD 1 … 1 R

This observation is of clinical status, as indicated by the <code> element. This element must be present.

(eHDdotsion)
@code
 		CONF 0 … 1 F 33999-4
@codeSystem
 		0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@codeSystemName
 		0 … 1 F LOINC
@displayName
 		0 … 1 F Status
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.

(eHDdotsion)
hl7:reference
 		TEL 1 … 1 M (eHDdotsion)
@value
 		1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 		CS 1 … 1 M

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

(eHDdotsion)
@code
 		CONF 1 … 1 F completed
hl7:value
 		CE.EPSOS 1 … 1 R The element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT. (eHDdotsion)
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.15 eHDSIStatusCode (DYNAMIC)