hl7:observation
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R |
This entry is an adaptation of the IHE Allergies And Intolerances Entry and IHE Problem
Entry (IHE PCC).
Note: including the templateId '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.
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(eHDces) |
@classCode
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cs |
1 … 1 |
F |
OBS |
@moodCode
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cs |
1 … 1 |
F |
EVN |
@negationInd
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bl |
0 … 1 |
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hl7:templateId
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II.EPSOS |
1 … 1 |
M |
eHDSI Allergies And Intolerances |
(eHDces) |
@root
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uid |
1 … 1 |
F |
1.3.6.1.4.1.12559.11.10.1.3.1.3.17 |
hl7:templateId
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II.EPSOS |
0 … 1 |
R |
IHE Problem Entry (IHE PCC) |
(eHDces) |
@root
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uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.4.5 |
hl7:templateId
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II.EPSOS |
0 … 1 |
R |
IHE Allergies And Intolerances Entry (IHE PCC) |
(eHDces) |
@root
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uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.4.6 |
hl7:templateId
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II.EPSOS |
0 … 1 |
R |
Alert observation (CCD) |
(eHDces) |
@root
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uid |
1 … 1 |
F |
2.16.840.1.113883.10.20.1.18 |
hl7:templateId
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II.EPSOS |
0 … 1 |
R |
Problem observation (CCD) |
(eHDces) |
@root
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uid |
1 … 1 |
F |
2.16.840.1.113883.10.20.1.28 |
hl7:id
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II.EPSOS |
0 … * |
R |
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(eHDces) |
hl7:code
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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.
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(eHDces) |
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CONF |
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hl7:text
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ED |
1 … 1 |
R |
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(eHDces) |
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hl7:reference
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TEL |
1 … 1 |
M |
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(eHDces) |
@value
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1 … 1 |
R |
Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 |
hl7:statusCode
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CS |
1 … 1 |
R |
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(eHDces) |
@code
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CONF |
0 … 1 |
F |
completed |
hl7:effectiveTime
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IVL_TS |
0 … 1 |
R |
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(eHDces) |
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Choice |
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The coded form of the observation value can be used:
- to contain a description of the allergy or adverse reaction.
- to indicate known absent conditions or the nonavailability of information.
Elements to choose from:
- hl7:value[1]
- hl7:value[2]
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hl7:value
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CD |
0 … 1 |
C |
A description of the allergy or adverse reaction. The preferred approach would be
to include the agent in the participant structure. If distinct agent data cannot be
provided, a 'diagnosis' can be included in the value.
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(eHDces) |
where [1] |
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hl7:value
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CD |
0 … 1 |
C |
When the value is used to describe the absence of information, the participant used
for indicating the allergy agent shall be omitted.
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(eHDces) |
where [2] |
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CONF |
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hl7:participant
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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.
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(eHDces) |
@typeCode
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cs |
1 … 1 |
F |
CSM |
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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.
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hl7:participantRole
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|
1 … 1 |
R |
|
(eHDces) |
@classCode
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cs |
1 … 1 |
F |
MANU |
hl7:playingEntity
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1 … 1 |
R |
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(eHDces) |
@classCode
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cs |
1 … 1 |
F |
MMAT |
hl7:code
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CD.EPSOS |
1 … 1 |
R |
Code for the substance causing the allergy or intolerance. |
(eHDces) |
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CONF |
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hl7:name
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PN |
0 … * |
R |
Name for the substance causing the allergy or intolerance. |
(eHDces) |
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hl7:entryRelationship
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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 Problem Entry structure.
Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.7 eHDSI Problem (DYNAMIC)
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(eHDces) |
@typeCode
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cs |
1 … 1 |
F |
MFST |
hl7:entryRelationship
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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 eHDSI Severity entry template (1.3.6.1.4.1.12559.11.10.1.3.1.3.8).
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 1.3.6.1.4.1.12559.11.10.1.3.1.3.8 eHDSI Severity (DYNAMIC)
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(eHDces) |
@typeCode
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cs |
1 … 1 |
F |
SUBJ |
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Example |
<!-- The encompasing condition or allergy observation --> <observation classCode="COND" moodCode="EVN"> <!-- ... --> <entryRelationship typeCode="SUBJ" inversionInd="true"> <observation classCode="OBS" moodCode="EVN"> <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.8"/> <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 eHDSISeverity value set --> <value type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/> </observation> </entryRelationship> <!-- ... --> </observation> |
hl7:entryRelationship
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0 … * |
R |
Criticality
The contained entry describes the gravity of the potential risk for future life-threatening
adverse reactions when exposed to a substance known to cause an adverse reaction in
that individual.
Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.33 eHDSI Criticality Observation (DYNAMIC)
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(eHDces) |
@typeCode
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cs |
1 … 1 |
F |
SUBJ |
hl7:entryRelationship
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|
0 … * |
R |
Certainty or Verification Status
The contained entry describes the certainty associated with a propensity, or potential
risk, of a reaction to the identified substance.
Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.35 eHDSI Allergy Certainty Observation (DYNAMIC)
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(eHDces) |
@typeCode
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cs |
1 … 1 |
F |
SUBJ |
hl7:entryRelationship
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|
0 … * |
R |
Status of the Allergy or Intolerance
The contained entry describes the current status of the allergy or intolerance, for
example, whether it is active, in remission, resolved, and so on ...
Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.34 eHDSI Allergy Status Observation (DYNAMIC)
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(eHDces) |
@typeCode
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cs |
1 … 1 |
F |
REFR |