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pending Template  IHE Problem Entry

Id 1.3.6.1.4.1.19376.1.5.3.1.4.5
ref
ch-pcc-
Effective Date 2016‑11‑12
Status pending Under pre-publication review Version Label 2016
Name IHEProblemEntry Display Name IHE Problem Entry
Description

This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.

Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5
Label 6.3.4.14
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 2 transactions and 7 templates, Uses 3 templates
Used by as Name Version
cdachemed-transaction-6 Transaction draft Pharmaceutical Advice document 2018‑04‑04 15:36:35
cdachemed-transaction-7 Transaction draft Medication List document 2018‑04‑04 15:37:19
1.3.6.1.4.1.19376.1.5.3.1.4.6 Containment pending IHE Allergies And Intolerances Entry (2016) 2016‑11‑12
2.16.756.5.30.1.1.10.4.81 link pending Pharmaceutical Advice Concern Entry Content Module (2017) 2016‑01‑11 11:13:04
2.16.756.5.30.1.1.10.4.44 link pending Pharmaceutical Advice Item Entry Content Module (2020) 2016‑06‑25
2.16.756.5.30.1.1.10.3.12 link pending Pharmaceutical Advice Section Content Module (2017) 2016‑06‑06
2.16.756.5.30.1.1.10.1.6 link pending Pharmaceutical Advice document (2020) 2016‑05‑21
2.16.756.5.30.1.1.10.3.44 link pending Medication List Section Content Module (2017) 2018‑01‑22 15:40:38
2.16.756.5.30.1.1.10.1.13 link pending Medication List document (2020) 2018‑01‑22 15:17:26
Uses as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.1 Containment pending IHE Severity Entry (2016) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.1 Containment cancelled IHE Problem Status Observation (2016) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.2 Containment cancelled IHE Health Status Observation (2014) DYNAMIC
Relationship Version: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (2016‑09‑26 09:50:55)
ref
IHE-PCC-

Specialization: template 2.16.840.1.113883.10.20.1.28 Problem observation (DYNAMIC)
ref
ccd1-
Item DT Card Conf Description Label
hl7:observation
R

The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed).

The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations, or which do not allow the negation to be recorded with post-coordinated coded terminology.

6.3.4.14
@moodCode
cs 1 … 1 F EVN
hl7:templateId
II 1 … 1 R 6.3.4.14
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II 1 … 1 R 6.3.4.14
@root
uid 1 … 1 F 2.16.840.1.113883.10.20.1.28
hl7:id
II 1 … 1 M 6.3.4.14
hl7:code
CD 1 … 1 R 6.3.4.14
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
6.3.4.14
hl7:statusCode
CS 0 … 1 R

A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.

6.3.4.14
@code
CONF 0 … 1 F completed
hl7:effectiveTime
IVL_TS 0 … 1 R 6.3.4.14
hl7:value
CD 1 … * R 6.3.4.14
hl7:originalText
0 … 1 R

The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus 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.

6.3.4.14
hl7:reference
0 … 1 R 6.3.4.14
hl7:entryRelationship
0 … 1 R
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 IHE Severity Entry (DYNAMIC)
6.3.4.14
hl7:entryRelationship
0 … 1 R



Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 IHE Problem Status Observation (DYNAMIC)
6.3.4.14
@typeCode
cs 1 … 1 F REFR
hl7:entryRelationship
0 … 1 R
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 IHE Health Status Observation (DYNAMIC)
6.3.4.14
@typeCode
cs 1 … 1 F REFR