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active Template  IHE Problem Status Observation

Id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
ref
IHE-PCC-
 		Effective Date 2013‑12‑20
Status active Active Version Label 2014
Name IHEProblemStatusObservation Display Name IHE Problem Status Observation
Description

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA  Schema. The clinical status observation records information about the current status of the  problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The  example below shows the recording of clinical status of a condition or allergy, and is used as the  context for the following sections.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
Label 6.3.4.4
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 0 templates
Used by as Name Version
2.16.756.5.30.1.1.10.4.106 Containment draft Problem Entry (2018) 2017‑09‑15 08:59:41
2.16.756.5.30.1.1.10.4.105 link draft Problem Concern Entry (2018) 2017‑09‑15 08:35:10
2.16.756.5.30.1.1.10.3.59 link draft Active Problems Section - coded (2018) 2017‑09‑13 19:41:44
2.16.756.5.30.1.1.10.1.11 link draft Social-medical care plan V2 (2018) 2017‑08‑24 18:00:03
Relationship Specialization: template 2.16.840.1.113883.10.20.1.50 Problem status observation (DYNAMIC)
ref
ccd1-

Specialization: template 2.16.840.1.113883.10.20.1.57 Status observation (DYNAMIC)
ref
ccd1-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.57"/>  <templateId root="2.16.840.1.113883.10.20.1.50"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.1"/>  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#cstatus-2"/>  </text>  <statusCode code="completed"/>  <value xsi:type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></observation>
Item DT Card Conf Description Label
hl7:observation
 6.3.4.4
hl7:templateId
 II 1 … 1 M 6.3.4.4
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.57
hl7:templateId
 II 1 … 1 M 6.3.4.4
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.50
hl7:templateId
 II 1 … 1 M 6.3.4.4
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
hl7:code
 CD 1 … 1 M

This observation is of clinical status, as indicated by the <code> element. This element must be present.

6.3.4.4
@code
 CONF 1 … 1 F 33999-4
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@displayName
 1 … 1 F Status
@codeSystemName
 1 … 1 F LOINC
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.

6.3.4.4
hl7:reference
 TEL 1 … 1 M 6.3.4.4
hl7:statusCode
 CS 1 … 1 R

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

6.3.4.4
@code
 CONF 0 … 1 F completed
@codeSystem
 0 … 1 F 2.16.840.1.113883.5.14 (ActStatus)
hl7:value
 CE 1 … 1 M The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT. 6.3.4.4
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.5.3.1.11.2 ProblemStatusObservation_value (2016‑09‑26 13:58:58)