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# Template IHE Problem Entry

Id | 1.3.6.1.4.1.19376.1.5.3.1.4.5 ref ch-pcc- | Effective Date | 2016‑11‑12
Status | Under pre-publication review | Version Label | 2016
Name | IHEProblemEntry | Display Name | IHE 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 (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below. Parent Template This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28
Context | Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5
Label | 6.3.4.14
Classification | CDA Entry Level Template
Open/Closed | Open (other than defined elements are allowed)
Used by / Uses |
Used by 2 transactions and 7 templates, Uses 3 templates
Used by | as | Name | Version
--- | --- | --- | ---
cdachemed-transaction-6 | Transaction | Pharmaceutical Advice document | 2018‑04‑04 15:36:35
cdachemed-transaction-7 | Transaction | Medication List document | 2018‑04‑04 15:37:19
1.3.6.1.4.1.19376.1.5.3.1.4.6 | Containment | IHE Allergies And Intolerances Entry (2016) | 2016‑11‑12
2.16.756.5.30.1.1.10.4.81 |  | Pharmaceutical Advice Concern Entry Content Module (2017) | 2016‑01‑11 11:13:04
2.16.756.5.30.1.1.10.4.44 |  | Pharmaceutical Advice Item Entry Content Module (2022) | 2022‑06‑30 15:10:57
2.16.756.5.30.1.1.10.3.12 |  | Pharmaceutical Advice Section Content Module (2017) | 2016‑06‑06
2.16.756.5.30.1.1.10.1.6 |  | Pharmaceutical Advice document (2020) | 2016‑05‑21
2.16.756.5.30.1.1.10.3.44 |  | Medication List Section Content Module (2021) | 2018‑01‑22 15:40:38
2.16.756.5.30.1.1.10.1.13 |  | Medication List document (2020) | 2018‑01‑22 15:17:26
Uses | as | Name | Version
1.3.6.1.4.1.19376.1.5.3.1.4.1 | Containment | IHE Severity Entry (2016) | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.1 | Containment | IHE Problem Status Observation (2014) | DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.2 | Containment | IHE Health Status Observation (2014) | DYNAMIC
Relationship | Version: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (2016‑09‑26 09:50:55) ref IHE-PCC- Specialization: template 2.16.840.1.113883.10.20.1.28 Problem observation (DYNAMIC) ref ccd1-
Item | DT | Card | Conf | Description | Label
--- | --- | --- | --- | --- | ---
hl7:observation |  |  | R | The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed). The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations, or which do not allow the negation to be recorded with post-coordinated coded terminology. | 6.3.4.14
@moodCode | cs | 1 … 1 | F | EVN
hl7:templateId | II | 1 … 1 | R |  | 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 | R |  | 6.3.4.14
@root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.28
hl7:id | II | 1 … 1 | M |  | 6.3.4.14
hl7:code | CD | 1 … 1 | R |  | 6.3.4.14
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 | 6.3.4.14
hl7:statusCode | CS | 0 … 1 | R | A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'. | 6.3.4.14
@code | CONF | 0 … 1 | F | completed
hl7:effectiveTime | IVL_TS | 0 … 1 | R |  | 6.3.4.14
hl7:value | CD | 1 … * | R |  | 6.3.4.14
hl7:originalText |  | 0 … 1 | R | The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus 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. | 6.3.4.14
hl7:reference |  | 0 … 1 | R |  | 6.3.4.14
hl7:entryRelationship |  | 0 … 1 | R | Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 IHE Severity Entry (DYNAMIC) | 6.3.4.14
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) | 6.3.4.14
@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) | 6.3.4.14
@typeCode | cs | 1 … 1 | F | REFR