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draft Template  Problem Entry

Id 2.16.756.5.30.1.1.10.4.106 Effective Date 2017‑09‑15 08:59:41
Status draft Draft Version Label 2018
Name cdachsmcp_entry_ProblemEntry Display Name 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 ( ) that problem. The of the observation comes from a controlled vocabulary representing such things. The contained within the describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.106
Label CDA‑CH‑SMCP
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 4 templates
Used by as Name Version
2.16.756.5.30.1.1.10.4.105 Containment 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
Uses as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.1 Containment active IHE Severity Entry (2014) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.1 Containment active IHE Problem Status Observation (2014) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.2 Containment active IHE Health Status Observation (2014) DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.2 Containment active IHE Comment Entry (2014) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.4.97 Problem Entry (DYNAMIC)
ref
ch-pcc-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (2016‑09‑26 09:50:55)
ref
?

Specialization: template 2.16.840.1.113883.10.20.1.28 Problem observation (DYNAMIC)
ref
ccd1-
Example
Example
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="2.16.756.5.30.1.1.10.4.106"/>  <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"/>  <id root="BAA96E2C-BF1F-4018-AC23-24AE06CE9E38"/>  <code code="282291009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem"/>  <text>
    <reference value="#your_content_id"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20120801"/>    <high nullFlavor="UNK"/>  </effectiveTime>  <value xsi:type="CD" code="N18.9" codeSystem="2.16.756.5.30.1.126.3.2" codeSystemName="ICD-10" displayName="Chronic kidney disease, unspecified">
    <originalText>
      <reference value="#your_content_id"/>    </originalText>  </value>  <entryRelationship typeCode="SUBJ">
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.1 'IHE Severity Entry' -->
  </entryRelationship>  <entryRelationship typeCode="REFR">
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 'IHE Problem Status Observation' -->
  </entryRelationship>  <entryRelationship typeCode="REFR">
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 'IHE Health Status Observation' -->
  </entryRelationship>  <entryRelationship typeCode="SUBJ">
    <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' -->
  </entryRelationship></observation>
Item DT Card Conf Description Label
hl7:observation
 R CDA-dotsSMCP
@classCode
 cs 1 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
@negationInd
 cs 1 … 1 R
  CONF
@negationInd shall be "false"
or
@negationInd shall be "true"
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.106
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.97
hl7:templateId
 II 1 … 1 R CDA-dotsSMCP
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
 II 1 … 1 R CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.28
hl7:id
 II 1 … 1 M CDA-dotsSMCP
hl7:code
 CD 1 … 1 R CDA-dotsSMCP
@displayName
 st 0 … 1  
@codeSystemName
 st 0 … 1  
@codeSystem
 oid 0 … 1  
@code
 cs 0 … 1  
@nullFlavor
 cs 0 … 1  
  Schematron assert role red error  
  test (@displayName and @codeSystem and @codeSystemName and @code) or (@nullFlavor)  
  Message Either a code with its attributes @displayName, @codeSystem, @codeSystemName and @code or a nullFlavor is required.  
hl7:text
 ED 1 … 1 R CDA-dotsSMCP
hl7:reference
 TEL 0 … 1 CDA-dotsSMCP
@value
 st 1 … 1 R
hl7:statusCode
 CS 1 … 1 M CDA-dotsSMCP
@code
 CONF 1 … 1 F completed
hl7:effectiveTime
 IVL_TS 0 … 1 R CDA-dotsSMCP
hl7:low
 IVXB_TS CDA-dotsSMCP
hl7:high
 IVXB_TS CDA-dotsSMCP
hl7:value
 CD 1 … * R CDA-dotsSMCP
hl7:originalText
 1 … 1 R CDA-dotsSMCP
hl7:reference
 0 … 1 R CDA-dotsSMCP
@value
 st 1 … 1 R
hl7:entryRelationship
 0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 IHE Severity Entry (DYNAMIC) CDA-dotsSMCP
treeblank where [hl7:observation [hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.4.1'] and hl7:templateId [@root = '2.16.840.1.113883.10.20.1.55']]]
@typeCode
 cs 1 … 1 F SUBJ
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) CDA-dotsSMCP
treeblank where [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']]]
@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) CDA-dotsSMCP
treeblank where [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']]]
@typeCode
 cs 1 … 1 F REFR
hl7:entryRelationship
 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC) CDA-dotsSMCP
treeblank where [hl7:act [hl7:templateId [@root = '2.16.840.1.113883.10.20.1.40'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.4.2']]]
@typeCode
 cs 1 … 1 F SUBJ