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Template IHE Problem Status Observation 2013‑12‑20

Id1.3.6.1.4.1.19376.1.5.3.1.4.1.1
ref
IHE-PCC-
Effective Date2013‑12‑20
Statusactive ActiveVersion Label2014
NameIHEProblemStatusObservationDisplay NameIHE Problem Status Observation
Description
en-US

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA  Schema. The clinical status observation records information about the current status of the  problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The  example below shows the recording of clinical status of a condition or allergy, and is used as the  context for the following sections.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
Label6.3.4.4
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 9 transactions and 32 templates, Uses 0 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.4.9Transactiondraft en-US IHE Emergency Department Referral2017‑03‑30 09:26:33
1.3.6.1.4.1.19376.1.5.3.1.4.10Transactiondraft en-US IHE Discharge Summary2017‑03‑30 09:27:43
2.16.840.1.113883.3.1937.777.11.4.23Transactiondraft en-US Return MRO
nl-NL Opleveren MRO		2013‑11‑02
1.3.6.1.4.1.19376.1.5.3.1.4.12Transactiondraft en-US IHE PHR Extract2017‑03‑30 09:29:02
1.3.6.1.4.1.19376.1.5.3.1.4.11Transactiondraft en-US IHE Immunization Content2017‑03‑30 09:28:26
2.16.840.1.113883.3.1937.777.11.4.12Transactiondraft en-US Return PS of country A
nl-NL Opleveren PS van land A		2012‑05‑02
2.16.840.1.113883.3.1937.777.49.4.2Transactiondraft (cs-CZ) Initial
en-US PS created		2022‑05‑19 08:45:25
2.16.840.1.113883.3.1937.777.11.4.21Transactiondraft en-US Send HCER to country A
nl-NL Stuur HCER naar land A		2013‑11‑02
1.3.6.1.4.1.19376.1.5.3.1.4.4Transactiondraft en-US IHE Referral Summary2016‑09‑29 13:42:51
1.2.203.24341.11.10.1.1linkdraft CZ-Patient Summary2019‑11‑08 19:31:50
1.2.203.24341.11.10.1.1linkdraft CZ-EU Patient Summary2019‑11‑28 20:23:19
1.3.6.1.4.1.12559.11.10.1.3.1.1.3linkdraft epSOS-Patient Summary2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4linkdraft epSOS-Health Care Encounter Report2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5linkdraft epSOS-Medication Related Overview2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.1.3linkactive IHE Referral Summary Document (2014)2016‑09‑29 13:41:44
1.3.6.1.4.1.19376.1.5.3.1.1.4linkactive IHE Discharge Summary Specification (2016)2017‑03‑20 14:34:30
1.3.6.1.4.1.19376.1.5.3.1.1.5linkactive IHE PHR Extract Specification (2016)2017‑03‑20 14:10:24
1.3.6.1.4.1.19376.1.5.3.1.1.10linkactive IHE Emergency Department Referral Specification (2016)2017‑03‑20 10:34:16
1.3.6.1.4.1.19376.1.5.3.1.1.18.1.2linkactive IHE Immunization Content Specification (2016)2017‑03‑20 09:59:31
1.3.6.1.4.1.19376.1.5.3.1.3.6linkdraft Section Active Problems2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8linkdraft Section History of Past Illness2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13linkdraft Section Allergies and Other Adverse Reactions2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23linkdraft Section Immunizations2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5Containmentdraft Problem2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5Containmentactive IHE Problem Entry (2014)2016‑09‑26 09:50:55
1.3.6.1.4.1.19376.1.5.3.1.4.5Containmentpending IHE Problem Entry (2016)2016‑11‑12
1.3.6.1.4.1.19376.1.5.3.1.4.5.2linkdraft Problem Concern2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3linkdraft Allergy and Intolerance Concern2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6Containmentactive IHE Allergies And Intolerances Entry (2014)2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6Containmentpending IHE Allergies And Intolerances Entry (2016)2016‑11‑12
1.3.6.1.4.1.19376.1.5.3.1.4.12linkdraft Immunizations2013‑12‑20
1.3.6.1.4.1.19376.1.9.1.1.1linkdraft Pharmacy Prescription Document (PRE2016)2016‑01‑07 22:13:03
1.3.6.1.4.1.19376.1.9.1.1.4linkdraft Community Medication Administration Document Content Module (rev. 1.1)2018‑03‑02 14:08:00
1.3.6.1.4.1.19376.1.9.1.1.6linkdraft IHE Community Medication Treatment Plan Document Content Module (Rev. 1.3)2017‑04‑03 07:57:37
1.3.6.1.4.1.19376.1.9.1.1.6linkcancelled IHE Medication Treatment Plan Document Content Module (2017)2018‑01‑17 17:33:23
2.16.756.5.30.1.1.10.1.8linkpending Patient Plan of Care (2013)2013‑10‑04
2.16.756.5.30.1.1.10.3.33linkpending Admission Diagnosis Section - coded (2016)2016‑11‑11
2.16.756.5.30.1.1.10.3.34linkpending Discharge Diagnosis Section - coded (2016)2016‑11‑11
2.16.756.5.30.1.1.10.4.73linkpending Concern Entry (2016)2016‑11‑11
2.16.756.5.30.1.1.10.4.81linkdraft Pharmaceutical Advice Concern Entry Content Module (2017)2016‑01‑11 11:13:04
2.16.756.5.30.1.1.10.4.106Containmentdraft Problem Entry (2018)2017‑09‑15 08:59:41
RelationshipSpecialization: template 2.16.840.1.113883.10.20.1.50 Problem status observation (DYNAMIC)
ref
ccd1-

Specialization: template 2.16.840.1.113883.10.20.1.57 Status observation (DYNAMIC)
ref
ccd1-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.57"/>  <templateId root="2.16.840.1.113883.10.20.1.50"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.1"/>  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#cstatus-2"/>  </text>  <statusCode code="completed"/>  <value xsi:type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
6.3.4.4
hl7:templateId
II1 … 1M6.3.4.4
@root
uid1 … 1F2.16.840.1.113883.10.20.1.57
hl7:templateId
II1 … 1M6.3.4.4
@root
uid1 … 1F2.16.840.1.113883.10.20.1.50
hl7:templateId
II1 … 1M6.3.4.4
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.1.1
hl7:code
CD1 … 1Men-US

This observation is of clinical status, as indicated by the <code> element. This element must be present.

6.3.4.4
@code
CONF1 … 1F33999-4
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@displayName
1 … 1FStatus
@codeSystemName
1 … 1FLOINC
hl7:text
ED1 … 1Men-US

The <text> element is required and 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.

6.3.4.4
hl7:reference
TEL1 … 1M6.3.4.4
hl7:statusCode
CS1 … 1Ren-US

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

6.3.4.4
@code
CONF0 … 1Fcompleted
@codeSystem
0 … 1F2.16.840.1.113883.5.14
hl7:value
CE1 … 1Men-US The <value> element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT.6.3.4.4
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.19376.1.5.3.1.11.2 (2016‑09‑26 13:58:58)