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rejected Template  Allergy Or Intolerance Entry

Id 2.16.756.5.30.1.1.10.4.98
ref
ch-pcc-
 		Effective Date 2016‑11‑11
Other versions this id:
Status rejected Rejected Version Label 2016
Name chpcc_entry_AllergyOrIntolerance Display Name Allergy Or Intolerance Entry
Description

Allergies or intolerances are a special form of a 'Problem Entry'.

In relation with immunizations, substances in vaccines SHALL be recorded here, using the WHO ATC Code along with a possible additional egg-protein allergy or a severe eczema.

Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.98
Label IHE PCC TF2 Rev.11, 6.3.4.15
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 7 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
2.16.756.5.30.1.1.10.4.97 Containment active Problem Entry (2016) DYNAMIC
2.16.756.5.30.1.1.10.4.99 Containment active Severity Entry (2016) DYNAMIC
2.16.756.5.30.1.1.10.4.100 Containment active Problem Status Observation (2016) DYNAMIC
2.16.756.5.30.1.1.10.4.2 Containment active Annotation Comments (2016) DYNAMIC
Relationship Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 eHDSI Allergies And Intolerances (DYNAMIC)
ref
epsos-

Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.756.5.30.1.1.10.4.98"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>  <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="your id"/>  <code code="DINT" codeSystem="2.16.840.1.113883.5.4" displayName="Drug Intolerance"/>  <text>
    <reference value="#ar1"/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value="20121213"/>  </effectiveTime>  <value xsi:type="CD" code="303300008" codeSystem="2.16.840.1.113883.6.96" displayName="Egg protein (substance)"/></observation>
Item DT Card Conf Description Label
hl7:observation

Allergies or intolerances are a special form of a 'Problem Entry'.

In relation with immunizations, substances in vaccines SHALL be recorded here, using the WHO ATC Code along with a possible additional egg-protein allergy or a severe eczema.

IHE PCC TF2 Rev.11, 6.3.4.15
@classCode
 		cs 1 … 1 F OBS
@moodCode
 		cs 1 … 1 F EVN
hl7:templateId
 		II 1 … 1 IHE PCC TF2 Rev.11, 6.3.4.15
@root
 		uid 1 … 1 F 2.16.756.5.30.1.1.10.4.98
hl7:templateId
 		II 1 … 1 IHE PCC TF2 Rev.11, 6.3.4.15
@root
 		uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.6
hl7:templateId
 		II 1 … 1 IHE PCC TF2 Rev.11, 6.3.4.15
@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, 6.3.4.15
@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, 6.3.4.15
@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 allergy or intolerance type code. IHE PCC TF2 Rev.11, 6.3.4.15
@code
 		cs 1 … 1 R
@codeSystem
 		oid 1 … 1 F 2.16.840.1.113883.5.4
@codeSystemName
 		st 1 … 1 F ObservationIntoleranceType
@displayName
 		st 1 … 1 R
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19700 ObservationIntoleranceType (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19701 ObservationAllergyType (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19702 ObservationNonAllergyIntoleranceType (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 allergies and intolerances.

 IHE PCC TF2 Rev.11, 6.3.4.15
  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 allergy or intolerance is known to be true. IHE PCC TF2 Rev.11, 6.3.4.15
hl7:low
 		TS.CH.TZ 1 … 1 M Point of time of the first occurance of the allergy or intolerance. IHE PCC TF2 Rev.11, 6.3.4.15
hl7:high
 		TS.CH.TZ 0 … 1 C Point of time when the allergy or intolerance was no longer valid. For all other cases this value remains empty. IHE PCC TF2 Rev.11, 6.3.4.15
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
  • SNOMED CT: 2.16.840.1.113883.6.96

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 Allergies/Intolerances" SHALL be used.

In relation to eVACDOC, the value set 'Allergies for eVACDOC' contains the recommended values.

IHE PCC TF2 Rev.11, 6.3.4.15
@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 "2.16.840.1.113883.6.96"
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.68 Special Case Allergies/Intolerances (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.756.5.30.1.1.11.76 Allergies for eVACDOC (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 allergy or intolerance. 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, 6.3.4.15
hl7:participant
 		1 … * R This element SHALL indicate the substance which causes the allergy or intolerance. IHE PCC TF2 Rev.11, 6.3.4.15
@typeCode
 		cs 1 … 1 F CSM
hl7:participantRole
 		IHE PCC TF2 Rev.11, 6.3.4.15
@classCode
 		cs 1 … 1 F MANU
hl7:playingEntity
 		1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.15
@classCode
 		cs 1 … 1 F MMAT
hl7:code
 		CD 1 … 1 R IHE PCC TF2 Rev.11, 6.3.4.15
@nullFlavor
 		st 0 … 1 F NAV
@code
 		cs 0 … 1  
@codeSystem
 		oid 0 … 1 F 2.16.840.1.113883.6.73
@codeSystemName
 		st 0 … 1 F WHO ATC
@displayName
 		st 0 … 1  
  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 allergies or intolerances 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:name
 		ST 0 … 1 IHE PCC TF2 Rev.11, 6.3.4.15
hl7:entryRelationship
 		0 … * Reactions that are manifestations of the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.97 Problem Entry (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='MFST']
@typeCode
 		cs 1 … 1 F MFST
hl7:entryRelationship
 		0 … 1 Indicates the severity of the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.99 Severity Entry (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='SUBJ']
@typeCode
 		cs 1 … 1 F SUBJ
@inversionInd
 		bl 1 … 1 F true
hl7:entryRelationship
 		0 … 1 Indicates the clinical status of the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.100 Problem Status Observation (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='REFR']
@typeCode
 		cs 1 … 1 F REFR
@inversionInd
 		bl 1 … 1 F false
hl7:entryRelationship
 		0 … * Additional comments (annotations) for the allergy or intolerance.
Contains 2.16.756.5.30.1.1.10.4.2 Annotation Comments (DYNAMIC) 		IHE PCC TF2 Rev.11, 6.3.4.15
where [@typeCode='SUBJ']
@typeCode
 		cs 1 … 1 F SUBJ
@inversionInd
 		bl 1 … 1 F true