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 0 transactions and 15 templates, Uses 3 templates
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.
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
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'.
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.
where [@typeCode='REFR'] [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.1.57']
and hl7:templateId [@root='2.16.840.1.113883.10.20.1.50'] and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.1.1']]]
where [@typeCode='REFR'] [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.20.1.51']
and hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.1.2']]]
Template IHE Problem Entry
Active
IHE Medication Treatment Plan Document Content Module (2017)
