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rejected Template  Problem Entry

Id 2.16.756.5.30.1.1.10.4.97
ref
ch-pcc-
 		Effective Date 2016‑11‑11
Other versions this id:
Status rejected Rejected Version Label 2016
Name chpcc_entry_Problem Display Name Problem Entry
Description Problem as structured entry (e.g. syptom, complaint, diagnosis etc.)
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.97
Label IHE PCC TF2 Rev.11, 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 0 templates, Uses 3 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
2.16.756.5.30.1.1.10.9.48 Containment active Author Compilation with name (2020) DYNAMIC
Relationship 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
Komplikationsrisiko eVACDOC
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <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"/>  <code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
    <originalText>
      <reference value="#pe-11"/>    </originalText>  </code>  <text>
    <reference value="#pe-12"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20140112"/>  </effectiveTime>  <value xsi:type="CD" code="114004" codeSystem="2.16.756.5.30.1.127.3.3.1" codeSystemName="Swiss Vaccination Plan Complication Risks" displayName="Schweres Asthma: bei verlängerter oder häufiger Behandlung mit oralen Steroiden"/></observation>
Example
Durchgemachte Krankheit
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <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="2.999" extension="9759b180"/>  <code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Problem">
    <originalText>
      <reference value="#hipi11"/>    </originalText>  </code>  <text>
    <reference value="#hipi12"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20121214"/>    <high value="20121221"/>  </effectiveTime>  <value xsi:type="CD" code="38907003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Chicken pox"/></observation>
Item DT Card Conf Description Label
hl7:observation
 		Problem as structured entry (e.g. syptom, complaint, diagnosis etc.) IHE PCC TF2 Rev.11, 6.3.4.14
@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 IHE PCC TF2 Rev.11, 6.3.4.14
@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, 6.3.4.14
@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, 6.3.4.14
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.1.28
hl7:id
 		II 0 … 1 R An ID for this item MAY be filled for traceability. IHE PCC TF2 Rev.11, 6.3.4.14
@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, 6.3.4.14
@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
  Constraint For eVACDOC complication or exposure risks, the code 55607006 (problem) MUST be used.
  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, 6.3.4.14
  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, 6.3.4.14
hl7:low
 		TS.CH.TZ 1 … 1 R Point of time of the first occurance of the problem. IHE PCC TF2 Rev.11, 6.3.4.14
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, 6.3.4.14
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:

  • CHOP: 2.16.756.5.30.1.126.3.1
  • ICD-10: 2.16.756.5.30.1.126.3.2
  • ICPC-2: 2.16.840.1.113883.6.139
  • VVK-EDI: 2.16.756.5.30.1.127.3.1.20080401.1
  • SNOMED CT: 2.16.840.1.113883.6.96
  • Swiss Vaccination Plan Complication Risks: 2.16.756.5.30.1.127.3.3.1
  • Swiss Vaccination Plan Exposure Risks: 2.16.756.5.30.1.127.3.3.2

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

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

 IHE PCC TF2 Rev.11, 6.3.4.14
@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 "2.16.756.5.30.1.126.3.1"
or
@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 "2.16.756.5.30.1.127.3.1.20080401.1"
or
@codeSystem shall be "2.16.840.1.113883.6.96"
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.72 Swiss Vaccination Plan Complication Risks (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.73 Swiss Vaccination Plan Exposure Risks (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.74 Special Case Problems (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.75 Illnesses undergone for immunization (DYNAMIC)
  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 … * This MAY be used to indicate who has documented the observation. This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.9.48 Author Compilation with name (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.14