| Item | DT | Card | Conf | Description | Label |
|---|
| | | R | | (IPS...nce) |
 | @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) |
| | 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. | (IPS...nce) |
| | hl7:reference
|
| TEL | 1 … 1 | M | | (IPS...nce) |
| | 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) |
| | 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) |
| | Constraint | If this condition is known to be resolved, then the effectiveTime/high would be present. |
| hl7:value
|
| CD.IPS (preferred) | 0 … 1 | C | The coded form shall be used to indicate known absent conditions (e.g. NKA) or the nonavailability of infos about them; or in some cases the allergy to specific substances (e.g. allergy to nuts).
When the value is present in a coded form, no allergy agent is expected to be provided. | (IPS...nce) |
| | CONF | | The value of @code comes preferably from value set 2.16.840.1.113883.11.22.10 Allergies to substances (DYNAMIC) | | or | | The value of @code comes preferably from value set 2.16.840.1.113883.11.22.9 Absent or Unknown Allergies (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) |
| | @typeCode
|
| cs | 1 … 1 | F | CSM |
| | Constraint | IF the observation/value element is present and coded then the observation/participant element SHALL be omitted.
Conditional: Omit if Observation.value is SNOMED-CT 160244002 No known Allergies |
| | hl7:participantRole
|
| | 0 … 1 | C | | (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) |
| | CONF | | The value of @code comes preferably from value set 2.16.840.1.113883.11.22.11 Adverse Reaction Agents (DYNAMIC) |
|
| | Schematron assert | role |  error | |
| | test | hl7:value[@code] or hl7:participantRole | |
| | Message | IF the observation/value element is present and coded then the observation/participant element SHALL be omitted | |
| | Schematron assert | role | error | |
| | test | hl7:value[@code] or hl7:participant/hl7:participantRole | |
| | Message | IF the observation/value element is present and coded then the observation/participant element SHALL be omitted | |
| 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) |
| where [@typeCode='MFST'] [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.6']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | MFST |
| | @inversionInd
|
| cs | 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) |
| where [@typeCode='SUBJ'] [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.18']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | SUBJ |
| | @inversionInd
|
| cs | 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 2.16.840.1.113883.10.22.4.19 IPS Certainty Observation (DYNAMIC) | (IPS...nce) |
| where [@typeCode='SUBJ'] [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.19']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | SUBJ |
| | @inversionInd
|
| cs | 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) |
| where [@typeCode='REFR'] [hl7:observation [hl7:templateId [@root='2.16.840.1.113883.10.22.4.21'] and hl7:templateId [@root='2.16.840.1.113883.10.22.4.20']]] |
| |
| | @typeCode
|
| cs | 1 … 1 | F | REFR |
| | @inversionInd
|
| cs | 1 … 1 | F | false |
Draft
