|
|
| (One intermediate revision by the same user not shown) |
| Line 5: |
Line 5: |
| | =Template ''IPSEntryAllergyOrIntolerance''= | | =Template ''IPSEntryAllergyOrIntolerance''= |
| | | | |
| − | <p>This template reflects a discrete observation about a patient's allergy or intolerance. | + | <p>This template reflects a discrete observation about a patient's allergy or intolerance. Because it is a discrete observation, it will have a statusCode of "completed".The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient.For a provider seeing a patient in the |
| − | Because it is a discrete observation, it will have a statusCode of "completed".The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient.For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.The effectiveTime of the Allergy - Intolerance Observation gives an indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". It is recommended that the agent responsible for an allergy or adverse reaction would be used for describing the allergy, however the possibility that pre-coordinate codes (e.g. "allergy to nuts") will be used has been here also considered.The agent responsible for an allergy or adverse reaction it is not always a manufactured material (for example, food allergies), nor is it necessarily consumed; however the playingEntity classCode = "MMAT" for all agents, manufactured or not is expected to be used. This choice depends on thecharacteristics of the base CDA R2 specification.</p>
| + | clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.The effectiveTime of the Allergy - Intolerance Observation gives an indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. If the date of |
| | + | resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". It is recommended that the agent responsible for an allergy or adverse reaction would be used for describing the allergy, however the possibility that pre-coordinate codes (e.g. "allergy to nuts") will be used has been here also considered.The agent responsible for an allergy |
| | + | or adverse reaction it is not always a manufactured material (for example, food allergies), nor is it necessarily consumed; however the playingEntity classCode = "MMAT" for all agents, manufactured or not is expected to be used. This choice depends on thecharacteristics of the base CDA R2 specification.</p> |
| | ==Actual version== | | ==Actual version== |
| | {{:{{BASEPAGENAME}}/dynamic}} | | {{:{{BASEPAGENAME}}/dynamic}} |
| | | | |
| | ==List of all versions of this template== | | ==List of all versions of this template== |
| | + | *[[2.16.840.1.113883.10.22.4.1/static-2024-08-04T094850|2024-08-04 09:48:50 (Under develeopment)]] |
| | *[[2.16.840.1.113883.10.22.4.1/static-2016-11-10T000000|2016-11-10 (Under pre-publication review)]] | | *[[2.16.840.1.113883.10.22.4.1/static-2016-11-10T000000|2016-11-10 (Under pre-publication review)]] |
| − | <!--5807fff21d2dc3da98ece5b16110a7621e43ef23--> | + | <!--1d2b608484fe36899aebbc85bf48a7b1d68024a0--> |
Template IPSEntryAllergyOrIntolerance
This template reflects a discrete observation about a patient's allergy or intolerance. Because it is a discrete observation, it will have a statusCode of "completed".The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient.For a provider seeing a patient in the
clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.The effectiveTime of the Allergy - Intolerance Observation gives an indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present. If the date of
resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". It is recommended that the agent responsible for an allergy or adverse reaction would be used for describing the allergy, however the possibility that pre-coordinate codes (e.g. "allergy to nuts") will be used has been here also considered.The agent responsible for an allergy
or adverse reaction it is not always a manufactured material (for example, food allergies), nor is it necessarily consumed; however the playingEntity classCode = "MMAT" for all agents, manufactured or not is expected to be used. This choice depends on thecharacteristics of the base CDA R2 specification.
Actual version
| Id | 2.16.840.1.113883.10.22.4.1 | Effective Date | 2024‑08‑04 09:48:50Other versions this id:  IPSEntryAllergyOrIntolerance as of 2016‑11‑10
|
|---|
| Status |  Draft | Version Label | STU2 |
|---|
| Name | IPSEntryAllergyOrIntolerance | Display Name | IPS Allergy or Intolerance |
|---|
| Description | This template reflects a discrete observation about a patient's allergy or intolerance. Because it is a discrete observation, it will have a statusCode of "completed".
The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient.
For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago.
The effectiveTime of the Allergy - Intolerance Observation gives an indication of whether or not the underlying allergy/intolerance is resolved. If known to be resolved, then an effectiveTime/high would be present.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
It is recommended that the agent responsible for an allergy or adverse reaction would be used for describing the allergy, however the possibility that pre-coordinate codes (e.g. "allergy to nuts") will be used has been here also considered.
The agent responsible for an allergy or adverse reaction it is not always a manufactured material (for example, food allergies), nor is it necessarily consumed; however the playingEntity classCode = "MMAT" for all agents, manufactured or not is expected to be used. This choice depends on thecharacteristics of the base CDA R2 specification.
|
|
| Context | Parent nodes of template element with id 2.16.840.1.113883.10.22.4.1 |
|---|
| Classification | CDA Entry Level Template |
|---|
| Open/Closed | Open (other than defined elements are allowed) |
|---|
| Associated with | | Associated with 12 concepts | | Id | Name | Data Set |
|---|
| hl7ips-dataelement-173 | Agent | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-182 | Allergies/Intolerances Content Status | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-184 | Allergy/Intolerance | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-185 | Diagnosis | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-186 | Clinical Status | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-187 | Onset date | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-188 | End Date | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-189 | Criticality | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-190 | Certainty | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-191 | Type of propensity | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-192 | Reaction | CEN/TC 251 prEN 17269 | | hl7ips-dataelement-196 | Agent code | CEN/TC 251 prEN 17269 |
|
|
|---|
| Uses | | Uses 4 templates | | Uses | as | Name | Version |
|---|
| 2.16.840.1.113883.10.22.4.6 | Containment | IPS Reaction Manifestation (STU2) | DYNAMIC | | 2.16.840.1.113883.10.22.4.18 | Containment |  IPS Criticality Observation (STU1) | DYNAMIC | | 2.16.840.1.113883.10.22.10 | Containment | IPS Allergy Certainty Observation (STU1) | DYNAMIC | | 2.16.840.1.113883.10.22.4.21 | Containment | IPS Allergy Status Observation (STU1) | DYNAMIC |
|
|
|---|
| Relationship | Specialization: template 2.16.840.1.113883.10.22.4.1 IPS Allergy or Intolerance (2016‑11‑10)
Adaptation: template 2.16.840.1.113883.10.20.1.18 Alert observation (DYNAMIC) ref ccd1-
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC) ref ch-pcc-
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.6 eHDSI Allergies And Intolerances (DYNAMIC) ref epsos- |
|---|
| Example | | Example | <observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.22.4.1"/> <id root=" " extension=" "/> <!-- This is the code that shows what kind of allergy or intolerance -->
<code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
<text>
<reference value="#ref1"/> </text> <statusCode code="completed"/> <effectiveTime>
<low value="20170701"/> </effectiveTime> <!-- This is the allergen - the substance that caused the allergy -->
<participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code=" " codeSystem=" ">
<originalText>
<reference value="#substance"/> </originalText> </code> <name>...</name> </playingEntity> </participantRole> </participant> <!-- This is how the allergy manifests itself -->
<entryRelationship typeCode="MFST" inversionInd="true">
<!-- template 2.16.840.1.113883.10.22.4.6 'IPS Reaction Manifestation' (dynamic) -->
</entryRelationship> <entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- template 2.16.840.1.113883.10.22.4.18 'IPS Criticality Observation' (dynamic) -->
</entryRelationship> <entryRelationship typeCode="SUBJ" inversionInd="true">
<!-- template 2.16.840.1.113883.10.22.4.19 'IPS Certainty Observation' (dynamic) -->
</entryRelationship> <entryRelationship typeCode="REFR" inversionInd="false">
<!-- template 2.16.840.1.113883.10.22.4.21 'IPS Allergy Status Observation' (dynamic) -->
</entryRelationship> </code></observation> |
|
|---|
| Example | | No Known Allergies | <observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.22.4.1"/> <code code="allergy" displayName="Allergy" codeSystem="2.16.840.1.113883.4.642.1.122">
<statusCode code="completed"/> <effectiveTime>
<low nullFlavor="UNK"/> </effectiveTime> <value code="X-NoKnownAllergy" displayName="No known allergy" codeSystem="2.16.840.1.113883.5.1150.2"/> </code></observation> |
|
|---|
| Example | | No Information available about allergies or intolerances | <observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.22.4.1"/> <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
<statusCode code="completed"/> <effectiveTime>
<low nullFlavor="NA"/> </effectiveTime> <value code="no-allergy-info" displayName="No information about allergies" codeSystem="2.16.840.1.113883.5.1150.1"/> </code></observation> |
|
|---|
| Example | | Minimum Set (active propensity; agent known) | <observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.22.4.1"/> <code code="OINT" displayName="Allergy or Intolerance" codeSystem="2.16.840.1.113883.5.4">
<statusCode code="completed"/> <effectiveTime>
<low nullFlavor="UNK"/> </effectiveTime> <participant typeCode="CSM">
<participantRole classCode="MANU">
<playingEntity classCode="MMAT">
<code code="13577000" codeSystem="2.16.840.1.113883.6.96" displayName="Nut"/> </playingEntity> </participantRole> </participant> </code></observation> |
|
|---|
| Item | DT | Card | Conf | Description | Label |
|---|
| | | R | | (IPS...nce) | | |  | | hl7ips-dataelement-184 | Allergy/Intolerance | CEN/TC 251 prEN 17269 |
|  | @classCode
|
| cs | 1 … 1 | F | OBS | | @moodCode
|
| cs | 1 … 1 | F | EVN | | hl7:templateId
|
| II | 1 … 1 | M | | (IPS...nce) |  | | @root
|
| uid | 1 … 1 | F | 2.16.840.1.113883.10.22.4.1 | | hl7:id
|
| II | 0 … * | R | | (IPS...nce) | | hl7:code
|
| CD.IPS | 1 … 1 | M | This element describes whether this condition refers to an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance). | (IPS...nce) | | | | | hl7ips-dataelement-191 | Type of propensity | CEN/TC 251 prEN 17269 |
| | | CONF | | The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.2 Allergy or Intolerance Type (DYNAMIC) |
| | hl7:text
|
| ED | 0 … 1 | R | The text element if present 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.</reference>
| (IPS...nce) | | | hl7:reference
|
| TEL | 1 … 1 | M | | (IPS...nce) | | url | 1 … 1 | R | When used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 | | hl7:statusCode
|
| CS | 1 … 1 | M | 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'.</statusCode>
| (IPS...nce) | | | @code
|
| cs | 1 … 1 | F | completed | | hl7:effectiveTime
|
| IVL_TS | 1 … 1 | M | The effectiveTime, also referred to as the "biologically relevant time" is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of penicillin allergy that developed five years ago, the effectiveTime is five years ago. The effectiveTime of the Allergy - Intolerance Observation may give an indication of whether or not the underlying allergy/intolerance is resolved.
The <low> and <high> values should be no more precise than known, but as precise as possible. | (IPS...nce) | | | hl7:low
|
| IVXB_TS | 1 … 1 | R | The effectiveTime/low (a.k.a. "onset date") asserts when the allergy/intolerance became biologically active. | (IPS...nce) | | | | | hl7ips-dataelement-187 | Onset date | CEN/TC 251 prEN 17269 |
| | | hl7:high
|
| IVXB_TS | 0 … 1 | C | The effectiveTime/high (a.k.a. "resolution date") asserts when the allergy/intolerance became biologically resolved.
If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". | (IPS...nce) | | | | | hl7ips-dataelement-188 | End Date | CEN/TC 251 prEN 17269 |
| | | Constraint | If this condition is known to be resolved, then the effectiveTime/high would be present. | | hl7:value
|
| CD.IPS (preferred) | 0 … 1 | | | (IPS...nce) | | | | | hl7ips-dataelement-185 | Diagnosis | CEN/TC 251 prEN 17269 |
| | | CONF | | The value of @code comes preferably from value set 2.16.840.1.113883.11.22.10 IPS Allergy or Intolerance Conditions (DYNAMIC) |
| | hl7:participant
|
| | 0 … 1 | C | The substance that causes the allergy or intolerance should be specified in the <participant> structure.
This is the preferred way an allergy is supposed to be expressed.
However it is recognized that in some contexts a controlled vocabulary is used for describing the allergy to a substance; or for asserting known absence or unavailability of information.
In this case the <participant> structure shall be omitted.
The agent responsible for an allergy or adverse reaction is not always a manufactured material (for example, food allergies), nor is it necessarily consumed. The following constraints reflect limitations in the base CDA R2 specification, and should be used to represent any type of responsible agent, i.e., use playingEntity classCode = "MMAT" for all agents, manufactured or not. | (IPS...nce) | | | | | hl7ips-dataelement-173 | Agent | CEN/TC 251 prEN 17269 |
| | | @typeCode
|
| cs | 1 … 1 | F | CSM | | | Constraint | IF the observation/value element is present and valued with a code derived form the 2.16.840.1.113883.11.22.9 Absent or Unknown Allergies value set THEN the observation/participant element used to describe the agent SHALL be omitted. | | | hl7:participantRole
|
| | 1 … 1 | R | | (IPS...nce) | | cs | 1 … 1 | F | MANU | | | 1 … 1 | R | | (IPS...nce) | | cs | 1 … 1 | F | MMAT | | CD.IPS (preferred) | 1 … 1 | R | Code for the substance causing the allergy or intolerance. | (IPS...nce) | | | | | hl7ips-dataelement-196 | Agent code | CEN/TC 251 prEN 17269 |
| | | CONF | | The value of @code comes preferably from value set 2.16.840.1.113883.11.22.65 IPS Allergy or Intolerance Substances (DYNAMIC) |
| | hl7:entryRelationship
|
| | 0 … * | R | The contained entry describes the reactions that are manifestations (typeCode='MFST') of the reported allergy or intolerance.
Contains 2.16.840.1.113883.10.22.4.6 IPS Reaction Manifestation (DYNAMIC) | (IPS...nce) | | | | | hl7ips-dataelement-192 | Reaction | CEN/TC 251 prEN 17269 |
| | | @typeCode
|
| cs | 1 … 1 | F | MFST | | | @inversionInd
|
| bl | 1 … 1 | F | true | | hl7:entryRelationship
|
| | 0 … 1 | R | Criticality
The contained entry describes the gravity of the potential risk for future life-threatening adverse reactions when exposed to a substance known to cause an adverse reaction in that individual.
Contains 2.16.840.1.113883.10.22.4.18 IPS Criticality Observation (DYNAMIC) | (IPS...nce) | | | | | hl7ips-dataelement-189 | Criticality | CEN/TC 251 prEN 17269 |
| | | @typeCode
|
| cs | 1 … 1 | F | SUBJ | | | @inversionInd
|
| bl | 1 … 1 | F | true | | hl7:entryRelationship
|
| | 0 … 1 | R | Certainty or Verification Status
The contained entry describes the certainty associated with a propensity, or potential risk, of a reaction to the identified substance.
Contains 2.16.840.1.113883.10.22.10 IPS Allergy Certainty Observation (DYNAMIC) | (IPS...nce) | | | | | hl7ips-dataelement-190 | Certainty | CEN/TC 251 prEN 17269 |
| | | @typeCode
|
| cs | 1 … 1 | F | SUBJ | | | @inversionInd
|
| bl | 1 … 1 | F | true | | hl7:entryRelationship
|
| | 0 … 1 | R | Status of the Allergy or Intolerance
The contained entry describes the current status of the allergy or intolerance, for example, whether it is active, in remission, resolved, and so on ...
Contains 2.16.840.1.113883.10.22.4.21 IPS Allergy Status Observation (DYNAMIC) | (IPS...nce) | | | | | hl7ips-dataelement-186 | Clinical Status | CEN/TC 251 prEN 17269 |
| | | @typeCode
|
| cs | 1 … 1 | F | REFR | | | @inversionInd
|
| bl | 1 … 1 | F | false |
|
List of all versions of this template
Draft
