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

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Revision as of 09:34, 25 July 2018

Id2.16.840.1.113883.10.22.4.8Effective Date2017‑02‑15
Other versions this id:
    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)
    Associated with
    Associated with 12 concepts
    IdNameData Set
    hl7ips-data​element-136Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-36Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-115Kyellow.png Problem content status Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-210Kyellow.png Problem Type Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-34Kyellow.png Date resolved Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-131Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-128Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-32Kyellow.png Onset Date Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-101Kyellow.png Problem type Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-209Kyellow.png Health condition / Problem Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-140Kyellow.png Problem Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-127Kyellow.png Onset date Kyellow.png CEN/TC 251 prEN 17269
    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="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="no-known-problems" displayName="No known problems" codeSystem="2.16.840.1.113883.5.1150.1"/></observation>
    ItemDTCardConfDescriptionLabel
    hl7:observation
    R(IPS...try)
     
    Target.png
    hl7ips-data​element-209Kyellow.png Health condition / Problem Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-140Kyellow.png Problem Kyellow.png CEN/TC 251 prEN 17269
    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)
     
    Target.png
    hl7ips-data​element-210Kyellow.png Problem Type Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-101Kyellow.png Problem type Kyellow.png CEN/TC 251 prEN 17269
     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"/>
    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.</reference></text>(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'.</statusCode>(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)
     
    Target.png
    hl7ips-data​element-32Kyellow.png Onset Date Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-127Kyellow.png Onset date Kyellow.png CEN/TC 251 prEN 17269
    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)
     
    Target.png
    hl7ips-data​element-34Kyellow.png Date resolved Kyellow.png CEN/TC 251 prEN 17269
     Constraint If this condition is known to be resolved, then the effectiveTime/high would be present.
    Treetree.pnghl7:value
    CD.IPS (preferred)1 … 1MThe <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)
     
    Target.png
    hl7ips-data​element-36Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-115Kyellow.png Problem content status Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-131Kyellow.png Diagnosis Kyellow.png CEN/TC 251 prEN 17269
    Treeblank.pngTreetree.png@xsi:type
    0 … 1FCD
     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"/>
    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. </reference></reference>(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)
    Treeblank.pngTreetree.pnghl7:qualifier
    CR0 … *(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.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-136Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
    hl7ips-data​element-128Kyellow.png Severity Kyellow.png CEN/TC 251 prEN 17269
    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.png where [hl7:observation [hl7:code [(@code = '66455-7' and @codeSystem = '2.16.840.1.113883.6.1')]]]
    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.png where [hl7:observation [hl7:code [(@code = '33999-4' and @codeSystem = '2.16.840.1.113883.6.1') or @nullFlavor]]]
    Treeblank.pngTreetree.png@typeCode
    cs1 … 1FREFR
    Treeblank.pngTreetree.png@inversionInd
    bl0 … 1Ffalse