Difference between revisions of "2.16.840.1.113883.10.22.4.8/static-2017-02-15T000000"

From HL7 IPS
Jump to: navigation, search
(Automated ADBot page content)
(Automated ADBot page content)
Line 1: Line 1:
<table
+
<table

Revision as of 16:14, 24 July 2017

Id2.16.840.1.113883.10.22.4.8Effective Date valid from 2017‑02‑15
StatusKyellow.png DraftVersion Label
NameIPSProblemEntryDisplay NameIPS 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".

ContextParent nodes of template element with id 2.16.840.1.113883.10.22.4.8
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 3 templates
Used by as NameVersion
2.16.840.1.113883.10.22.4.7ContainmentKyellow.png IPS Problem Concern Entry2017‑02‑15
2.16.840.1.113883.10.22.3.3Link.pngKyellow.png IPS Problems Section2017‑02‑15
2.16.840.1.113883.10.22.1.1Link.pngKyellow.png International Patient Summary2017‑04‑11
2.16.840.1.113883.10.22.3.7Link.pngKyellow.png IPS History of Past Illness Section2017‑04‑12
Uses as NameVersion
2.16.840.1.113883.10.22.4.25ContainmentKyellow.png IPS Severity ObservationDYNAMIC
2.16.840.1.113883.10.22.4.19ContainmentKyellow.png IPS Certainty ObservationDYNAMIC
2.16.840.1.113883.10.22.4.20ContainmentKyellow.png IPS Problem Status Observation2017‑03‑29
RelationshipAdaptation: 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="282291009" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.96"/>  <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 unknown)
<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="282291009" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.96"/>  <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="55607006" displayName="Problem" codeSystem="2.16.840.1.113883.6.96"/>  <statusCode code="completed"/>  <effectiveTime>
    <low nullFlavor="NI"/>  </effectiveTime>
  <value code="160245001" displayName="No current problems or disability" codeSystem="2.16.840.1.113883.6.96"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R(IPS…try)
Treetree.png@classCode
cs0 … 1FOBS
Treetree.png@moodCode
cs1 … 1FEVN
Treetree.pnghl7:templateId
II1 … 1M(IPS…try)
Treeblank.pngTreetree.png@root
uid1 … 1F2.16.840.1.113883.10.22.4.8
Treetree.pnghl7:id
II0 … *R(IPS…try)
Treetree.pnghl7:code
CD.IPS1 … 1RThis 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="282291009" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.96"/>
Treetree.pnghl7:text
ED0 … 1RThe <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>
Treeblank.pngTreetree.pnghl7:reference
TEL1 … 1M(IPS…try)
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
CS1 … 1MA 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)
Treeblank.pngTreetree.png@code
CONF1 … 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…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>
Treeblank.pngTreetree.pnghl7:low
IVXB_TS1 … 1RThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.
(IPS…try)
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…try)
 Constraint If this condition is known to be resolved, then the effectiveTime/high would be present.
Treetree.pnghl7:value
CD.IPS CNE1 … 1MThe <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 (xsi:type='CD'). 
If uncoded, all attributes other than xsi:type='CD' must be absent and - in this case - shall contain a <reference> to the <originalText> in the narrative where the allergy is described.
The coded form shall be used to indicate known absent conditions or the nonavailability of information about them.
(IPS…try)
Treeblank.pngTreetree.png@xsi:type
0 … 1FCD
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.5 CORE Problem List Disorders (DYNAMIC)
or
The value of @code shall be drawn from value set 2.16.840.1.113883.11.22.17 Absent or Unknown Problems (2017‑04‑07)
 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"/>
Treeblank.pngTreetree.pnghl7: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)
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…try)
 Example<reference value="#value_as_text"/>
Treeblank.pngTreetree.pnghl7:translation
CD.IPS0 … *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)
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…try)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1R 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)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FSUBJ
Treeblank.pngTreetree.png@inversionInd
bl1 … 1Ftrue
Treetree.pnghl7:entryRelationship
0 … 1RStatus 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)
Treeblank.pngTreetree.png@typeCode
cs1 … 1FREFR
Treeblank.pngTreetree.png@inversionInd
bl0 … 1Ffalse