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Template Allergy - Intolerance Observation 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.7Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameAllergy-IntoleranceObservationDisplay NameAllergy - Intolerance Observation
Description
This clinical statement represents that an allergy or adverse reaction exists or does not exist. The agent that is the cause of the allergy or adverse reaction is represented as a manufactured material participant playing entity in the allergy observation. While the agent is often implicit in the alert observation (e.g. ""allergy to penicillin""), it should also be asserted explicitly as an entity. The manufactured material participant is used to represent natural and non-natural occurring substances. NOTE: 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.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.7
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 6 transactions and 9 templates, Uses 4 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transactionfinal Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transactionfinal History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.30Containmentdraft Allergy Problem Act (1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.8Containmentdraft Severity Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.28Containmentdraft Allergy Status Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.145Containmentdraft Criticality Observation (2.1)2015‑08‑13
ItemDTCardConfDescriptionLabel
cda:observation
Alledotstion
@classCode
cs1 … 1FOBSconf‑7379
@moodCode
cs1 … 1FEVNconf‑7380
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:7381) such that itconf‑7381
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.7confdots0488
cda:id
II1 … *RSHALL contain at least one [1..*] id (CONF:7382).conf‑7382
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code (CONF:15947).confdots5947
@code
CONF1 … 1FASSERTION
@codeSystem
1 … 1F2.16.840.1.113883.5.4
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:19084).confdots9084
@code
CONF1 … 1Fcompleted
cda:effectiveTime
IVL_TS1 … 1RSHALL contain exactly one [1..1] effectiveTime (CONF:7387).

If it is unknown when the allergy began, this effectiveTime SHALL contain low/@nullFLavor="UNK"

If the allergy is no longer a concern, this effectiveTime MAY contain zero or one [0..1] high		conf‑7387
cda:value
CD1 … 1MSHALL contain exactly one [1..1] value with @xsi:type="CD" (CONF:7390).conf‑7390
@code
1 … 1Rconf‑9139
cda:originalText
0 … 1RThis value SHOULD contain zero or one [0..1] originalText (CONF:7422).conf‑7422
cda:reference
0 … 1The originalText, if present, MAY contain zero or one [0..1] reference (CONF:15949).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)		confdots5949
@value
0 … 1 confdots5950
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MessageThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:participant
0 … 1RSHOULD contain zero or one [0..1] participant (CONF:7402) such that itconf‑7402
@typeCode
cs1 … 1FCSMconf‑7403
cda:participantRole
1 … 1MSHALL contain exactly one [1..1] participantRole (CONF:7404).conf‑7404
@classCode
cs1 … 1FMANUconf‑7405
cda:playingEntity
1 … 1MThis participantRole SHALL contain exactly one [1..1] playingEntity (CONF:7406).conf‑7406
@classCode
cs1 … 1FMMATconf‑7407
cda:code
CD1 … 1RThis playingEntity SHALL contain exactly one [1..1] code, which SHALL be selected from ValueSet Substance-Reactant for Intolerance urn:oid:2.16.840.1.113762.1.4.1010.1 DYNAMIC (CONF:7419).
conf‑7419
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1010.1 Substance-Reactant for Intolerance (DYNAMIC)
cda:originalText
0 … 1RThis code SHOULD contain zero or one [0..1] originalText (CONF:7424).conf‑7424
cda:reference
0 … 1RThe originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:7425).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)		conf‑7425
@value
0 … 1 confdots5952
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MessageThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:translation
CD0 … *This code MAY contain zero or more [0..*] translation (CONF:7431).conf‑7431
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.28 Allergy Status Observation (2013‑01‑31)conf‑7440
@typeCode
cs1 … 1FSUBJconf‑7906
@inversionInd
bl1 … 1Ftrueconf‑7446
cda:entryRelationship
0 … *RContains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (2013‑01‑31)conf‑7447
@typeCode
cs1 … 1FMFSTconf‑7907
@inversionInd
bl1 … 1Ftrueconf‑7449
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.8 Severity Observation (2013‑01‑31)conf‑9961
@typeCode
cs1 … 1FSUBJconf‑9962
@inversionInd
bl1 … 1Ftrueconf‑9964
 ConstraintUse of the Severity Observation at this level of the Allergy-intolerance template is deprecated. It SHOULD NOT be used here.
 Schematron assertroleorange warning 
 testfalse() 
 MessageUse of the Severity Observation at this level of the Allergy-intolerance template is deprecated. It SHOULD NOT be used here. 
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.145 Criticality Observation (2015‑08‑13)confdots2910
@typeCode
cs1 … 1FSUBJconfdots2911
@inversionInd
bl1 … 1Ftrueconfdots2912