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ref Template  Problem Observation

Id 2.16.756.5.30.1.1.10.4.67 Effective Date valid from 2017‑09‑12 18:21:27
Status draft Draft Version Label 2017
Name ProblemObservation Display Name Problem Observation
Description Problem Diagnose Information
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.67
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 3 concepts
Id Name Data Set
cdachresp-dataelement-488 Ersteller Diagnose 1
cdachresp-dataelement-290 Diagnose (ICD-10) 1
cdachresp-dataelement-291 Diagnose-Art 1
Used by / Uses
Used by 0 transactions and 4 templates, Uses 1 template
Used by as Name Version
2.16.756.5.30.1.1.10.4.68 Containment draft Problem Concern Entry (2017) 2017‑09‑12 20:40:11
2.16.756.5.30.1.1.10.3.16 link draft Diagnosis (2017) 2017‑09‑08 10:23:39
2.16.756.5.30.1.1.10.1.2 link draft EmergencyMedicalServiceProtocol (2017) 2017‑06‑13 17:19:29
2.16.756.5.30.1.1.10.1.2 link cancelled EmergencyMedicalServiceProtocol (2017) 2017‑05‑31 17:19:29
Uses as Name Version
2.16.756.5.30.1.1.10.9.14 Include draft Narrative text reference (2017) DYNAMIC
Relationship Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (2016‑09‑26 09:50:55)
Specialization: template 2.16.840.1.113883.10.20.1.28 (DYNAMIC)
Example
Example
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.67"/>  <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"/>  <id root="AD092C2A-813D-4EAA-83F1-EB53DB2F16F0"/>  <code code="2931005" codeSystem="2.16.840.1.113883.6.96" displayName="Verdachtsdiagnose"/>  <text>
    <reference value="#diagnose1"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20161210112500.0000+0100"/>  </effectiveTime>  <value xsi:type="CD" code="I21.0" codeSystem="2.16.756.5.30.1.126.3.2" displayName="ST elevation (STEMI) myocardial infarction of anterior wall"/>  <author>
    <functionCode code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician">
      <translation code="309343006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Physician"/>    </functionCode>    <time value="20161210112500.0000+0100"/>    <assignedAuthor>
      <!-- cdachresp-dataelement-281 -->
      <id root="2.51.1.3" extension="7601000028105"/>    </assignedAuthor>  </author></observation>
Item DT Card Conf Description Label
hl7:observation
 R (Prodotsion)
@moodCode
 cs 1 … 1 F EVN
@classCode
 cs 1 … 1 F OBS
@negationInd
 bl 1 … 1 F false
hl7:templateId
 II 1 … 1 M (Prodotsion)
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.67
hl7:templateId
 II 1 … 1 R (Prodotsion)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
 II 1 … 1 R (Prodotsion)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.28
hl7:id
 II 1 … 1 M (Prodotsion)
hl7:code
 CD 1 … 1 R (Prodotsion)
 
target cdachresp-dataelement-291 Diagnose-Art 1
  CONF
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.24 IVR valueset diagnosis type (.143.11.16) (DYNAMIC)
Included 1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative text reference (DYNAMIC)
The reference to the text in the narrative section of the section MUST be specified.
hl7:text
 ED 1 … 1 M (Prodotsion)
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'] (Prodotsion)
@value
 1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding <content> 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 0 … 1 R (Prodotsion)
@code
 CONF 0 … 1 F completed
hl7:effectiveTime
 IVL_TS 0 … 1 R The low value is the earliest point for which the condition is known to have existed. The high value, when present, indicates the time at which the observation was no longer known to be true. (Prodotsion)
hl7:value
 CD 1 … 1 R An ICD-10 code has to be provided (Prodotsion)
 
target cdachresp-dataelement-290 Diagnose (ICD-10) 1
@codeSystem
 CONF 0 … 1 F 2.16.756.5.30.1.126.3.2
hl7:author
 1 … * R (Prodotsion)
 
target cdachresp-dataelement-488 Ersteller Diagnose 1
hl7:functionCode
 CE 1 … 1 R (Prodotsion)
hl7:time
 TS.CH.TZ 1 … 1 R Timestamp of the authorship. (Prodotsion)
hl7:assignedAuthor
 1 … 1 R (Prodotsion)
hl7:id
 II 1 … * R (Prodotsion)