Difference between revisions of "2.16.840.1.113883.10.22.4.6/static-2016-11-15T000000"

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Revision as of 09:35, 25 July 2018

Id2.16.840.1.113883.10.22.4.6Effective Date2016‑11‑15
Other versions this id:
    StatusKyellow.png DraftVersion Label
    NameIPSAdverseReactionMFSTDisplay NameIPS Reaction Manifestation
    Description
    This clinical statement represents the response to an undesired symptom, finding, etc. due to administered or exposed substance. This reaction may be an undesired symptom, finding, etc. or it could be a desired response to a treatment. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions.
    ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.6
    ClassificationCDA Entry Level Template
    Open/ClosedOpen (other than defined elements are allowed)
    Associated with
    Associated with 2 concepts
    IdNameData Set
    hl7ips-data​element-193Kyellow.png Manifestation of the reaction Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-194Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
    Used by / Uses
    Used by 0 transactions and 4 templates, Uses 1 template
    Used by as NameVersion
    2.16.840.1.113883.10.22.4.1ContainmentKyellow.png IPS Allergy or Intolerance2016‑11‑10
    2.16.840.1.113883.10.22.4.5Link.pngKyellow.png IPS Allergy and Intolerance Concern2016‑11‑11
    2.16.840.1.113883.10.22.3.2Link.pngKyellow.png IPS Allergies and Intolerances Section2016‑11‑11
    2.16.840.1.113883.10.22.1.1Link.pngKyellow.png International Patient Summary2017‑04‑11
    Uses as NameVersion
    2.16.840.1.113883.10.22.4.25ContainmentKyellow.png IPS Severity ObservationDYNAMIC
    RelationshipAdaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 (DYNAMIC)
    Example
    Example
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.22.4.6"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="404684003" displayName="Clinical finding" codeSystem="2.16.840.1.113883.6.96"/>  <text>
        <reference value="#ref1"/>  </text>
      <statusCode code="completed"/>  <effectiveTime>
        <low value="201611"/>  </effectiveTime>
      <value xsi:type="CD" code="1985008" displayName="Vomitus" codeSystem="2.16.840.1.113883.6.96">
        <originalText>
          <reference value="#ref2"/>    </originalText>
      </value>
      <entryRelationship typeCode="SUBJ" inversionInd="true">
        <!-- template 2.16.840.1.113883.10.22.4.25 'IPS Severity Observation' (dynamic) -->
      </entryRelationship>
    </observation>
    ItemDTCardConfDescriptionLabel
    hl7:observation
    R(IPS...FST)
    Treetree.png@classCode
    cs0 … 1FOBS
    Treetree.png@moodCode
    cs1 … 1FEVN
    Treetree.pnghl7:templateId
    II1 … 1M(IPS...FST)
    Treeblank.pngTreetree.png@root
    uid1 … 1F2.16.840.1.113883.10.22.4.6
    Treetree.pnghl7:id
    II0 … *R(IPS...FST)
    Treetree.pnghl7:code
    CD.IPS1 … 1R
    This element describes the type of condition this observation is referring to.
    (IPS...FST)
     CONF
    The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.16 Problem Type (2017‑04‑07)
    Treetree.pnghl7:text
    ED0 … 1R
    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...FST)
    Treeblank.pngTreetree.pnghl7:reference
    TEL1 … 1M(IPS...FST)
    Treeblank.pngTreeblank.pngTreetree.png@value
    1 … 1RWhen used it shall refer to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
    Treetree.pnghl7:statusCode
    CS (required)0 … 1R

    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...FST)
    Treeblank.pngTreetree.png@code
    CONF0 … 1Fcompleted
    Treetree.pnghl7:effectiveTime
    IVL_TS1 … 1M
    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...FST)
    Treeblank.pngTreetree.pnghl7:low
    IVXB_TS1 … 1RThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.(IPS...FST)
    Treeblank.pngTreetree.pnghl7:high
    IVXB_TS0 … 1CThe 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...FST)
     Constraint If this condition is known to be resolved, then the effectiveTime/high would be present.
    Treetree.pnghl7:value
    CD.IPS (preferred)1 … 1R
    The <value> is the condition that was found. While the value may be a coded or an un-coded string, the type is always a coded value. 
    If uncoded, it shall contain a <reference> to the <originalText> in the narrative where the reaction is described.
    (IPS...FST)
     
    Target.png
    hl7ips-data​element-193Kyellow.png Manifestation of the reaction Kyellow.png CEN/TC 251 prEN 17269
    Treeblank.pngTreetree.png@xsi:type
    1 … 1FCD
     CONF
    The value of @code comes preferably from value set 2.16.840.1.113883.11.22.3 Allergy Reaction (2017‑02‑23)
    Treeblank.pngTreetree.pnghl7:originalText
    0 … 1R

    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...FST)
    Treeblank.pngTreeblank.pngTreetree.pnghl7:reference
    0 … 1R 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...FST)
     Example<reference value="#AdvReaction_1"/>
    Treeblank.pngTreetree.pnghl7:translation
    CD0 … *(IPS...FST)
    Treetree.pnghl7:entryRelationship
    0 … 1RSeverity
    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...FST)
    Treeblank.png where [hl7:observation [hl7:code [concat(@code, @codeSystem) = doc('include/voc-2.16.840.1.113883.1.11.20386-DYNAMIC.xml')//valueSet [1]/conceptList/concept/concat(@code, @codeSystem) or @nullFlavor]]]
     
    Target.png
    hl7ips-data​element-194Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FSUBJ
    Treeblank.pngTreetree.png@inversionInd
    bl1 … 1Ftrue