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Template Health Concern Act (V2) 2015‑08‑01

Id2.16.840.1.113883.10.20.22.4.132Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameHealthConcernActV2Display NameHealth Concern Act (V2)
Description
This template represents a health concern. It is a wrapper for a single health concern which may be derived from a variety of sources within an EHR (such as Problem List, Family History, Social History, Social Worker Note, etc.). A Health Concern Act is used to track non-optimal physical or psychological situations drawing the patient to the healthcare system. These may be from the perspective of the care team or from the perspective of the patient. When the underlying condition is of concern (i.e., as long as the condition, whether active or resolved, is of ongoing concern and interest), the statusCode is “active”. Only when the underlying condition is no longer of concern is the statusCode set to “completed”. The effectiveTime reflects the time that the underlying condition was felt to be a concern; it may or may not correspond to the effectiveTime of the condition (e.g., even five years later, a prior heart attack may remain a concern). Health concerns require intervention(s) to increase the likelihood of achieving the goals of care for the patient and they specify the condition oriented reasons for creating the plan.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.132
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 2 templates, Uses 32 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.58Containmentdraft Health Concerns Section (V2) (2.1)2015‑08‑01
Uses as NameVersion
2.16.840.1.113883.10.20.15.3.8Containmentdraft Pregnancy Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.1Containmentdraft Result Organizer (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.2Containmentdraft Result Observation (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.3Containmentdraft Problem Concern Act (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.4Containmentdraft Problem Observation (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.7Containmentdraft Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.27Containmentdraft Vital Sign Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.34Containmentdraft Hospital Admission Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.38Containmentdraft Social History Observation (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.45Containmentdraft Family History Organizer (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.51Containmentdraft Postprocedure Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.65Containmentdraft Preoperative Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.67Containmentdraft Functional Status Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.69Containmentdraft Assessment Scale Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.72Containmentdraft Caregiver Characteristics (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.74Containmentdraft Mental Status Observation (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.78Containmentdraft Smoking Status - Meaningful Use (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.80Containmentdraft Encounter Diagnosis (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.85Containmentdraft Tobacco Use (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.109Containmentdraft Characteristics of Home Environment (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.111Containmentdraft Cultural and Religious Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.114Containmentdraft Longitudinal Care Wound Observation (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.115Containmentdraft External Document Reference (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.122Containmentdraft Entry Reference (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.124Containmentdraft Nutritional Status Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.127Containmentdraft Sensory Status (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.128Containmentdraft Self-Care Activities (ADL and IADL) (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.138Containmentdraft Nutrition Assessment (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.143Containmentdraft Priority Preference (2.1)2015‑08‑13
2.16.840.1.113883.10.20.24.3.90Containmentdraft Substance or Device Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
RelationshipSpecialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.132 Health Concern Act (V2) (DYNAMIC)
ItemDTCardConfDescriptionLabel
cda:act
HealdotsctV2
@classCode
cs1 … 1FACTCONFdots0750
 SHALL contain exactly one [1..1] @classCode="ACT" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-30750).
@moodCode
cs1 … 1FEVNCONFdots0751
 SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-30751).
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.132
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-30752) such that itCONFdots0752
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.132CONFdots0753
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.132" (CONF:1198-30753).
@extension
st1 … 1F2015-08-01CONFdots2861
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32861).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1198-30754).CONFdots0754
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code (CONF:1198-32310).CONFdots2310
@code
CONF1 … 1F75310-3
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:statusCode
CS1 … 1RSHALL contain exactly one [1..1] statusCode (CONF:1198-30758).CONFdots0758
cda:effectiveTime
0 … 1MAY contain zero or one [0..1] effectiveTime (CONF:1198-30759).CONFdots0759
cda:author
0 … *RSHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-31546).

A health concern may be a patient or provider concern. If the author is set to the recordTarget (patient), this is a patient concern. If the author is set to a provider, this is a provider concern. If both patient and provider are set as authors, this is a concern of both the patient and the provider.
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)
CONFdots1546
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01)CONFdots0761
where [@typeCode='REFR']
@typeCode
cs1 … 1FREFRCONFdots0762
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-30762).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.7 Allergy - Intolerance Observation (V2) (2014‑06‑09)CONFdots1007
@typeCode
cs1 … 1FREFRCONFdots1008
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31008).
cda:entryRelationship
0 … *The following entryRelationship represents the relationship between two Health Concern Acts where there is a general relationship between the source and the target (Health Concern REFERS TO Health Concern). For example, a patient has 2 health concerns identified in a CARE Plan: Failure to Thrive and Poor Feeding, while it could be that one may have caused the other, at the time of care planning and documentation it is not necessary, nor desirable to have to assert what caused what. The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)
CONFdots1157
where [@typeCode='REFR']
@typeCode
cs1 … 1FREFRCONFdots1158
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31158).
cda:entryRelationship
0 … *The following entryRelationship represents the relationship between two Health Concern Acts where the target is a component of the source (Health Concern HAS COMPONENT Health Concern). For example, a patient has an Impaired Mobility Health Concern. There may then be the need to document several component health concerns, such as "Unable to Transfer Bed to Chair", "Unable to Rise from Commode", "Short of Breath Walking with Walker". The Entry Reference template is used here because the target Health Concern Act will be defined elsewhere in the Health Concerns Section and thus a reference to that template is all that is required.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)
CONFdots1160
where [@typeCode='COMP']
@typeCode
cs1 … 1FCOMPCONFdots1161
 SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31161).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (2015‑08‑13)CONFdots1190
@typeCode
cs1 … 1FREFRCONFdots1191
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31191).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.128 Self-Care Activities (ADL and IADL) (2015‑08‑13)CONFdots1232
@typeCode
cs1 … 1FREFRCONFdots1264
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31264).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.74 Mental Status Observation (V3) (2015‑08‑01)CONFdots1234
@typeCode
cs1 … 1FREFRCONFdots1268
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31268).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.78 Smoking Status - Meaningful Use (V2) (2014‑06‑09)CONFdots1235
@typeCode
cs1 … 1FREFRCONFdots1269
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31269).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.80 Encounter Diagnosis (V3) (2015‑08‑01)CONFdots1236
@typeCode
cs1 … 1FREFRCONFdots1270
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31270).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.45 Family History Organizer (V3) (2015‑08‑01)CONFdots1237
@typeCode
cs1 … 1FREFRCONFdots1279
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers To (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31279).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.67 Functional Status Observation (V2) (2014‑06‑09)CONFdots1238
@typeCode
cs1 … 1FREFRCONFdots1282
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31282).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.34 Hospital Admission Diagnosis (V3) (2015‑08‑01)CONFdots1241
@typeCode
cs1 … 1FREFRCONFdots1291
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31291).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.138 Nutrition Assessment (2015‑08‑13)CONFdots1244
@typeCode
cs1 … 1FREFRCONFdots1300
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31300).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.51 Postprocedure Diagnosis (V3) (2015‑08‑01)CONFdots1246
@typeCode
cs1 … 1FREFRCONFdots1306
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31306).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.15.3.8 Pregnancy Observation (2015‑08‑13)CONFdots1247
@typeCode
cs1 … 1FREFRCONFdots1309
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31309).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.65 Preoperative Diagnosis (V3) (2015‑08‑01)CONFdots1248
@typeCode
cs1 … 1FREFRCONFdots1312
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31312).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09)CONFdots1250
@typeCode
cs1 … 1FREFRCONFdots1318
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31318).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.2 Result Observation (V3) (2015‑08‑01)CONFdots1251
@typeCode
cs1 … 1FREFRCONFdots1321
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31321).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.127 Sensory Status (2015‑08‑13)CONFdots1252
@typeCode
cs1 … 1FREFRCONFdots1324
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31324).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.38 Social History Observation (V3) (2015‑08‑01)CONFdots1253
@typeCode
cs1 … 1FREFRCONFdots1327
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31327).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.24.3.90 Substance or Device Allergy - Intolerance Observation (V2) (2014‑06‑09)CONFdots1254
@typeCode
cs1 … 1FREFRCONFdots1330
 MAY contain zero or one [0..1] typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31330).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.85 Tobacco Use (V2) (2014‑06‑09)CONFdots1255
@typeCode
cs1 … 1FREFRCONFdots1333
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31333).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.27 Vital Sign Observation (V2) (2014‑06‑09)CONFdots1256
@typeCode
cs1 … 1FREFRCONFdots1336
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31336).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.114 Longitudinal Care Wound Observation (V2) (2015‑08‑01)CONFdots1257
@typeCode
cs1 … 1FREFRCONFdots1339
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31339).
cda:entryRelationship
0 … *The following entryRelationship represents the relationship Health Concern HAS SUPPORT Observation.
Contains 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01)
CONFdots1365
where [@typeCode='SPRT']
@typeCode
cs1 … 1FSPRTCONFdots1366
 SHALL contain exactly one [1..1] @typeCode="SPRT" Has support (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31366).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.72 Caregiver Characteristics (2015‑08‑13)CONFdots1368
@typeCode
cs1 … 1FREFRCONFdots1369
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31369).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.111 Cultural and Religious Observation (2015‑08‑13)CONFdots1371
@typeCode
cs1 … 1FREFRCONFdots1372
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31372).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.109 Characteristics of Home Environment (2015‑08‑13)CONFdots1374
@typeCode
cs1 … 1FREFRCONFdots1375
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31375).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.124 Nutritional Status Observation (2015‑08‑13)CONFdots1377
@typeCode
cs1 … 1FREFRCONFdots1378
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31378).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.1 Result Organizer (V3) (2015‑08‑01)CONFdots1380
@typeCode
cs1 … 1FREFRCONFdots1381
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31381).
cda:entryRelationship
0 … *The following entryRelationship represents the priority that the patient or a provider puts on the health concern.
Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13)
CONFdots1442
@typeCode
cs1 … 1FREFRCONFdots1443
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31443).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.3 Problem Concern Act (V3) (2015‑08‑01)CONFdots1544
@typeCode
cs1 … 1FREFRCONFdots1547
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31547).
cda:entryRelationship
0 … *Where a Health Concern needs to reference another entry already described in the CDA document instance, rather than repeating the full content of the entry, the Entry Reference template may be used to reference this entry.
Contains 2.16.840.1.113883.10.20.22.4.122 Entry Reference (2015‑08‑13)
CONFdots1549
@typeCode
cs1 … 1FREFRCONFdots1550
 SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-31550).
cda:reference
0 … *Where it is necessary to reference an external clinical document such a Referral document, Discharge Summary document etc., the External Document Reference template can be used to reference this document. However, if this Care Plan document is replacing or appending another Care Plan document in the same set, that relationship is set in the header, using ClinicalDocument/relatedDocument.
Contains 2.16.840.1.113883.10.20.22.4.115 External Document Reference (2014‑06‑09)
CONFdots2757
@typeCode
cs1 … 1FREFRCONFdots2758
 The reference, if present, SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-32758).