2.16.840.1.113883.10.22.4.8/static-2017-02-15T000000

Id	2.16.840.1.113883.10.22.4.8	Effective Date	valid from 2017‑02‑15
Status	Draft	Version Label
Name	IPSProblemEntry	Display Name	IPS Problem Entry
Description This template reflects a discrete observation about a patient's problem. 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 heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is 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".
Context	Parent nodes of template element with id 2.16.840.1.113883.10.22.4.8
Classification	CDA Entry Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 4 templates, Uses 3 templates Used by as Name Version 2.16.840.1.113883.10.22.4.7 Containment IPS Problem Concern Entry 2017‑02‑15 2.16.840.1.113883.10.22.3.3 IPS Problems Section 2017‑02‑15 2.16.840.1.113883.10.22.1.1 International Patient Summary 2017‑04‑11 2.16.840.1.113883.10.22.3.7 IPS History of Past Illness Section 2017‑04‑12 Uses as Name Version 2.16.840.1.113883.10.22.4.25 Containment IPS Severity Observation DYNAMIC 2.16.840.1.113883.10.22.4.19 Containment IPS Certainty Observation DYNAMIC 2.16.840.1.113883.10.22.4.20 Containment IPS Problem Status Observation 2017‑03‑29
Relationship	Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (DYNAMIC)
Example	Active Problem <observation classCode="OBS" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <text>     <reference value="#problem-1"/>  </text>  <statusCode code="completed"/>  <effectiveTime>     <low value="20100507"/>  </effectiveTime>  <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <entryRelationship typeCode="SUBJ" inversionInd="true">     <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity 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 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->     <!-- this referred observation should report that the condition is still active -->   </entryRelationship></observation>
Example	Closed Problem (resolution date known) <observation classCode="OBS" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>     <low value="2010"/>    <high value="2015"/>  </effectiveTime>  <value code="38341003" displayName="Hypertensive disorder, systemic arterial (disorder)" codeSystem="2.16.840.1.113883.6.96"/>  <entryRelationship typeCode="SUBJ" inversionInd="true">     <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity 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 2.16.840.1.113883.10.22.4.20 'IPS Problem Status Observation' (2017-03-29T00:00:00) -->     <!-- this referred observation should report that the condition is resolved -->   </entryRelationship></observation>
Example	Known absent problems <observation classCode="OBS" moodCode="EVN">   <templateId root="2.16.840.1.113883.10.22.4.8"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/>  <statusCode code="completed"/>  <effectiveTime>     <low nullFlavor="NI"/>  </effectiveTime>  <value code="X-NoCurrentProblems" displayName="No current problems or disability" codeSystem="2.16.840.1.113883.3.1937.777.13.5.999.1"/></observation>
Item DT Card Conf Description Label hl7:observation R (IPS...try) @classCode cs 0 … 1 F OBS @moodCode cs 1 … 1 F EVN hl7:templateId II 1 … 1 M (IPS...try) @root uid 1 … 1 F 2.16.840.1.113883.10.22.4.8 hl7:id II 0 … * R (IPS...try) hl7:code CD.IPS 1 … 1 R This element describes the type of condition this observation is referring to. (IPS...try)   CONF The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.16 Problem Type (DYNAMIC)   Example <code code="75326-9" codeSystem="2.16.840.1.113883.6.1" displayName="Problem"/> 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. (IPS...try)   Example <text>   <reference value="#problem-1"/></text> hl7:reference TEL 1 … 1 M (IPS...try) @value 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'. (IPS...try) @code CONF 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 heart attack that occurred five years ago, the effectiveTime is five years ago. The <low> and <high> values should be no more precise than known, but as precise as possible. (IPS...try)   Example Known onset date (active condition) <effectiveTime>   <low value="20100507"/></effectiveTime>   Example Unknown onset date (active condition) <effectiveTime>   <low nullFlavor="UNK"/></effectiveTime>   Example Unknown resolution date <effectiveTime>   <low value="2010"/>  <high nullFlavor="UNK"/></effectiveTime>   Example Known resolution date <effectiveTime>   <low value="201007"/>  <high value="201703"/></effectiveTime> hl7:low IVXB_TS 1 … 1 R The effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active. (IPS...try) hl7:high IVXB_TS 0 … 1 C The effectiveTime/high (a.k.a. "resolution date") asserts when the condition e became biologically resolved. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK". (IPS...try)   Constraint If this condition is known to be resolved, then the effectiveTime/high would be present. hl7:value CD.IPS (preferred) 1 … 1 M The <value> is the condition that was found. It may a coded or an un-coded string, but its type is always coded. The coded form shall be used also to indicate known absent conditions or the nonavailability of information about them. (IPS...try) @xsi:type 0 … 1 F CD   CONF The value of @code comes preferably from value set 2.16.840.1.113883.11.22.5 CORE Problem List Disorders (DYNAMIC) or The value of @code comes preferably from value set 2.16.840.1.113883.11.22.17 Absent or Unknown Problems (DYNAMIC)   Example Multiple Coding <value code="302231008" displayName="Salmonella infection" codeSystem="2.16.840.1.113883.6.96">   <translate code="A02.9" displayName="Infezioni da Salmonella non specificate" codeSystem="2.16.840.1.113883.6.3"/></value>   Example Local code not mappable in the reference terminology <value nullFlavor="OTH">   <translate code="12345" displayName="Not in the reference value set" codeSystem="1.2.3.999" codeSystemName="--example only--"/></value>   Example Textual Information <value nullFlavor="NI">   <originalText>     <reference value="#value_as_text"/>  </originalText></value>   Example Known absent problems <value code="160245001" displayName="No current problems or disability" codeSystem="2.16.840.1.113883.6.96"/> hl7:originalText 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. (IPS...try) hl7:reference 0 … 1 R The URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. In a CDA document, the URI given in the value attribute of the <reference> element points to an element in the narrative content that contains the complete text describing the medication. (IPS...try)   Example <reference value="#value_as_text"/> hl7:translation CD.IPS 0 … * The translation element may be used to transmit a set of other concept descriptors, using for example ICD-10 or other international or jurisdictional code systems. (IPS...try) hl7:qualifier CR 0 … * (IPS...try) hl7:entryRelationship 0 … 1 R Severity The contained entry describes a subjective assessment of the severity of the condition as evaluated by the clinician. Contains 2.16.840.1.113883.10.22.4.25 IPS Severity Observation (DYNAMIC) (IPS...try) where [@typeCode='SUBJ'] [hl7:observation [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.22.4.25']]] @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 condition. Contains 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation (DYNAMIC) (IPS...try) where [@typeCode='SUBJ'] [hl7:observation [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.22.4.19']]] @typeCode cs 1 … 1 F SUBJ @inversionInd bl 1 … 1 F true hl7:entryRelationship 0 … 1 R Status of the Problem   The contained entry describes the current status of the condition, for example, whether it is active, in remission, resolved, and so on ... Contains 2.16.840.1.113883.10.22.4.20 IPS Problem Status Observation (2017‑03‑29) (IPS...try) where [@typeCode='REFR'] [hl7:observation [hl7:templateId ​[@root​=​'2.16.840.1.113883.10.22.4.20']]] @typeCode cs 1 … 1 F REFR @inversionInd bl 0 … 1 F false