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.
|
(eHD ces) |
@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 |
(eHD ces) |
@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 |
(eHD ces) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.20.1.18 |
hl7:templateId
|
II.EPSOS |
1 … 1 |
R |
|
(eHD ces) |
@root
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.20.1.28 |
hl7:templateId
|
II.EPSOS |
1 … 1 |
R |
|
(eHD ces) |
@root
|
uid |
1 … 1 |
F |
1.3.6.1.4.1.19376.1.5.3.1.4.6 |
hl7:id
|
II.EPSOS |
0 … * |
R |
|
(eHD ces) |
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.
|
(eHD ces) |
|
|
|
CONF |
|
hl7:text
|
ED |
1 … 1 |
R |
|
(eHD ces) |
|
|
hl7:reference
|
TEL |
1 … 1 |
M |
|
(eHD ces) |
@value
|
|
1 … 1 |
R |
Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 |
hl7:statusCode
|
CS |
1 … 1 |
R |
|
(eHD ces) |
@code
|
CONF |
0 … 1 |
F |
completed |
hl7:effectiveTime
|
IVL_TS |
0 … 1 |
R |
|
(eHD ces) |
|
|
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:
- no-allergy-info
- no-known-allergies
- no-known-medication-allergies
- no-known-environmental-allergies
- no-known-food-allergies
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|
|
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.
|
(eHD ces) |
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.
|
(eHD ces) |
@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 |
|
(eHD ces) |
@classCode
|
cs |
1 … 1 |
F |
MANU |
hl7:playingEntity
|
|
1 … 1 |
R |
|
(eHD ces) |
@classCode
|
cs |
1 … 1 |
F |
MMAT |
hl7:code
|
CD.EPSOS |
1 … 1 |
R |
Code for the substance causing the allergy or intolerance. |
(eHD ces) |
|
|
|
CONF |
|
hl7:name
|
PN |
0 … * |
R |
Name for the substance causing the allergy or intolerance. |
(eHD ces) |
|
|
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)
|
(eHD ces) |
@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)
|
(eHD ces) |
@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> |