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active Template  Reaction Observation

Id 2.16.756.5.30.1.1.10.4.120
ref
ch-pcc-
Effective Date 2016‑11‑12
Other versions this id:
Status active Active Version Label 2016
Name chpcc_entry_ReactionObservation Display Name Reaction Observation
Description Reaction as structured entry
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.120
Label IHE PCC TF2 Rev.11, 6.3.4.15.10
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 4 templates
Uses as Name Version
2.16.756.5.30.1.1.10.9.14 Include active Narrative Text Reference (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.49 Include active Original Text Reference (2017) DYNAMIC
2.16.756.5.30.1.1.10.9.54 Containment active Author Compilation with id, name, addr and telecom (2020) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.12.1 Containment active IHE Antigen Dose entry (2014) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.4.97 Problem Entry (2016‑11‑12)
ref
ch-pcc-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
ch-pcc-

Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.120"/>  <templateId root="2.16.756.5.30.1.1.10.4.97"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>  <templateId root="2.16.840.1.113883.10.20.1.28"/>  <templateId root="2.16.840.1.113883.10.20.1.54"/>  <id root="1.2.3.999" extension="extension"/>  <code code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName=""/>  <text>
    <reference value="#ref"/>  </text>
  <statusCode code="completed"/>  <effectiveTime>
    <low value="20200429130414+02:00"/>    <high value="20200429130414+02:00"/>  </effectiveTime>
  <value code="" codeSystem="" codeSystemName="" displayName=""/>  <author>
    <!-- template 2.16.756.5.30.1.1.10.9.54 'Author Compilation with id, name, addr and telecom' -->
  </author>
</observation>
Item DT Card Conf Description Label
hl7:observation
Problem as structured entry (e.g. syptom, complaint, diagnosis etc.) IHE PCC TF2 Rev.11, 6.3.4.15.10
@classCode
cs 1 … 1 F OBS
@moodCode
cs 1 … 1 F EVN
@negationInd
bl 1 … 1 R This value remains usually 'false'. If there is an observation that the problem has not occured, this value can be set 'true'. This is a small but important difference to the situation where the problem has not been observed (and therefore no problem has been recorded).
hl7:templateId
II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.4.120
hl7:templateId
II 1 … 1 IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.4.97
hl7:templateId
II 1 … 1 IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II 1 … 1 IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid 1 … 1 F 2.16.840.1.113883.10.20.1.28
hl7:templateId
II 1 … 1 IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid 1 … 1 F 2.16.840.1.113883.10.20.1.54
hl7:id
II 1 … * R Each adverse reaction SHALL have an identifier. IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid 1 … 1 R MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:code
CD 1 … 1 M The problem type code. IHE PCC TF2 Rev.11, 6.3.4.15.10
@code
cs 1 … 1 R
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.96
@codeSystemName
st 1 … 1 F SNOMED CT
@displayName
st 1 … 1 R
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.14 ProblemTypeCode (DYNAMIC)
Included 1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:text
ED 1 … 1 M CDA‑CH V2
hl7:reference
TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
hl7:statusCode
CS 1 … 1 M

The statusCode shall be set to 'completed' for all problems.

IHE PCC TF2 Rev.11, 6.3.4.15.10
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)
hl7:effectiveTime
IVL_TS.CH.TZ 1 … 1 R Indicates the time interval over which the problem is known to be true. IHE PCC TF2 Rev.11, 6.3.4.15.10
hl7:low
TS.CH.TZ 1 … 1 R Point of time of the first occurance of the problem. IHE PCC TF2 Rev.11, 6.3.4.15.10
hl7:high
TS.CH.TZ 0 … 1 C Point of time when the problem was solved. For all other cases this value remains empty. IHE PCC TF2 Rev.11, 6.3.4.15.10
hl7:value
CD 0 … *

This value can be either a coded value or uncoded text. The type is always xsi:type='CD'. For coded values the attributes code, codeSystem, codeSystemName and displayName MUST be present. For uncoded values, the nullFlavor='NAV' attribute and the originalText element MUST be present.

The following value sets are allowed:

  • ICD-10: 2.16.756.5.30.1.126.3.2
  • ICPC-2: 2.16.840.1.113883.6.139
  • SNOMED CT: 2.16.840.1.113883.6.96

The SNOMED CT code 160245001, 'No current problems or disability (situation)' MAY be used to indicate that the patient doesn't currently has any reactions.

For special cases a code from the value set 'Special Case Problems' SHALL be used.

IHE PCC TF2 Rev.11, 6.3.4.15.10
@nullFlavor
st 0 … 1 F NAV
@code
cs 0 … 1  
@codeSystem
oid 0 … 1  
@codeSystemName
st 0 … 1  
@displayName
st 0 … 1  
  CONF
@codeSystem shall be "2.16.756.5.30.1.126.3.2"
or
@codeSystem shall be "2.16.840.1.113883.6.139"
or
@codeSystem shall be "2.16.840.1.113883.6.96"
  Schematron assert role red error  
  test (@code and @codeSystem) or (@nullFlavor='NAV')  
  Message Either a code with its code system or nullFlavor='NAV' is required.  
  Schematron assert role red error  
  test not(@nullFlavor) or (hl7:originalText)  
  Message Other problems description MUST be declared in the originalText element in case of nullFlavor.  
Included 0 … 1 C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:originalText
ED 0 … 1 C CDA‑CH V2
hl7:reference
TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
  Schematron assert role red error  
  test parent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text()  
  Message The originalText content MUST be identical to the narrative text for this reference.  
hl7:author
0 … * C The author of the statement SHALL be specified either here or in one of the ancestors.
Contains 2.16.756.5.30.1.1.10.9.54 Author Compilation with id, name, addr and telecom (DYNAMIC)
IHE PCC TF2 Rev.11, 6.3.4.15.10
  Schematron assert role red error  
  test (hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]] or ancestor::*/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]])  
  Message The author of the statement SHALL be specified either here or in one of the ancestors. It shall contain the time, id, name, addr and telecom elements as specified in IHE PCC TF Vol. 2, section 6.3.4.1 Authors and Informants.  
  Schematron assert role yellow info  
  test (not(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) and ancestor::hl7:section/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]])  
  Message The author of the statement is specified by the ancestor section.  
  Schematron assert role yellow info  
  test (not(hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]] or ancestor::hl7:section/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]]) and ancestor::hl7:ClinicalDocument/hl7:author[hl7:time and hl7:assignedAuthor[hl7:id and hl7:addr and hl7:telecom and (hl7:assignedPerson/hl7:name or hl7:representedOrganization/hl7:name)]])  
  Message The author of the statement is specified by the author in the document header.  
hl7:entryRelationship
0 … * Antigen doses applicable.
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.12.1 IHE Antigen Dose entry (DYNAMIC)
IHE PCC TF2 Rev.11, 6.3.4.15.10
where [@typeCode='COMP']