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Template IHE Problem Entry 2016‑11‑12

Id1.3.6.1.4.1.19376.1.5.3.1.4.5
ref
ch-pcc-
Effective Date2016‑11‑12
Statuspending Under pre-publication reviewVersion Label2016
NameIHEProblemEntryDisplay NameIHE Problem Entry
Description

This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.

Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5
Label6.3.4.14
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 40 templates, Uses 3 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.9.4Containmentactive IHE Reason for Procedure Section (2016)2017‑03‑27 08:47:54
1.3.6.1.4.1.19376.1.5.3.1.1.9.16Containmentactive IHE General Appearance Section (2014)2016‑10‑21 13:17:36
1.3.6.1.4.1.19376.1.5.3.1.1.9.17Containmentactive IHE Integumentary System Section (2016)2017‑03‑16 15:54:34
1.3.6.1.4.1.19376.1.5.3.1.1.9.18Containmentactive IHE Head Section (2016)2017‑03‑16 15:46:23
1.3.6.1.4.1.19376.1.5.3.1.1.9.19Containmentactive IHE Eyes Section (2016)2017‑03‑16 15:36:07
1.3.6.1.4.1.19376.1.5.3.1.1.9.20Containmentactive IHE Ears, Nose, Mouth and Throat Section (2016)2017‑03‑16 15:25:05
1.3.6.1.4.1.19376.1.5.3.1.1.9.21Containmentactive IHE Ears Section (2016)2017‑03‑16 15:14:13
1.3.6.1.4.1.19376.1.5.3.1.1.9.22Containmentactive IHE Nose Section (2016)2017‑03‑16 15:03:04
1.3.6.1.4.1.19376.1.5.3.1.1.9.23Containmentactive IHE Mouth, Throat and Teeth Section (2016)2017‑03‑16 14:54:35
1.3.6.1.4.1.19376.1.5.3.1.1.9.24Containmentactive IHE Neck Section (2016)2017‑03‑16 14:42:15
1.3.6.1.4.1.19376.1.5.3.1.1.9.25Containmentactive IHE Endocrine System Section (2016)2017‑03‑16 14:34:41
1.3.6.1.4.1.19376.1.5.3.1.1.9.26Containmentactive IHE Thorax and Lungs Section (2016)2017‑03‑16 14:26:12
1.3.6.1.4.1.19376.1.5.3.1.1.9.27Containmentactive IHE Chest Wall Section (2016)2017‑03‑16 14:18:17
1.3.6.1.4.1.19376.1.5.3.1.1.9.28Containmentactive IHE Breast Section (2016)2017‑03‑16 14:10:37
1.3.6.1.4.1.19376.1.5.3.1.1.9.29Containmentactive IHE Heart Section (2016)2017‑03‑16 13:50:39
1.3.6.1.4.1.19376.1.5.3.1.1.9.30Containmentactive Respiratory System Section (2014)2016‑10‑21 14:15:48
1.3.6.1.4.1.19376.1.5.3.1.1.9.31Containmentactive Abdomen Section (2014)2016‑10‑21 14:35:15
1.3.6.1.4.1.19376.1.5.3.1.1.9.32Containmentactive IHE Lymphatic System Section (2016)2017‑03‑16 13:42:16
1.3.6.1.4.1.19376.1.5.3.1.1.9.33Containmentactive IHE Vessels Section (2016)2017‑03‑16 13:35:11
1.3.6.1.4.1.19376.1.5.3.1.1.9.34Containmentactive IHE Musculoskeletal System Section (2016)2017‑03‑16 13:26:52
1.3.6.1.4.1.19376.1.5.3.1.1.9.35Containmentactive IHE Neurologic System Section (2016)2017‑03‑16 13:18:54
1.3.6.1.4.1.19376.1.5.3.1.1.9.36Containmentactive IHE Genitalia Section (2016)2017‑03‑16 13:10:34
1.3.6.1.4.1.19376.1.5.3.1.1.9.37Containmentactive IHE Rectum Section (2016)2017‑03‑16 12:42:17
1.3.6.1.4.1.19376.1.5.3.1.1.9.44Containmentactive IHE Pre-procedure Risk Assessment Section (2016)2017‑03‑24 09:21:23
1.3.6.1.4.1.19376.1.5.3.1.1.9.48Containmentactive IHE Visible Implanted Medical Devices Section (2016)2017‑03‑16 16:02:15
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9Containmentactive IHE ED Diagnosis Section (2016)2017‑03‑24 08:19:57
1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1Containmentactive IHE Extremities Section (2016)2017‑03‑16 10:16:28
1.3.6.1.4.1.19376.1.5.3.1.1.21.2.10Containmentactive IHE Pelvis Section (2016)2017‑03‑24 13:10:03
1.3.6.1.4.1.19376.1.5.3.1.3.2Containmentactive IHE Coded Reason for Referral Section (2014)2016‑09‑26 08:43:40
1.3.6.1.4.1.19376.1.5.3.1.4.5.1Containmentactive IHE Concern Entry (2014)2015‑09‑24 23:36:55
1.3.6.1.4.1.19376.1.5.3.1.4.5.2Containmentdraft Problem Concern2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.2Containmentactive IHE Problem Concern Entry (2014)2016‑09‑26 08:50:28
1.3.6.1.4.1.19376.1.5.3.1.4.5.3linkdraft Allergy and Intolerance Concern2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6Containmentdraft Allergies And Intolerances2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6Containmentpending IHE Allergies And Intolerances Entry (2016)2016‑11‑12
1.3.6.1.4.1.19376.1.5.3.1.4.6Containmentretired Allergies And Intolerances2018‑11‑19 09:27:03
1.3.6.1.4.1.19376.1.5.3.1.4.12Containmentdraft Immunizations2013‑12‑20
1.3.6.1.4.1.19376.1.7.3.1.1.13.7Containmentactive IHE Coded Event Outcomes (2016)2017‑03‑24 14:16:18
2.16.756.5.30.1.1.10.4.73Containmentpending Concern Entry (2016)2016‑11‑11
2.16.756.5.30.1.1.10.4.81Containmentdraft Pharmaceutical Advice Concern Entry Content Module (2017)2016‑01‑11 11:13:04
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.4.1Containmentpending IHE Severity Entry (2016)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.1Containmentactive IHE Problem Status Observation (2014)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.2Containmentactive IHE Health Status Observation (2014)DYNAMIC
RelationshipVersion: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (2016‑09‑26 09:50:55)
ref
IHE-PCC-

Specialization: template 2.16.840.1.113883.10.20.1.28 Problem observation (DYNAMIC)
ref
ccd1-
ItemDTCardConfDescriptionLabel
hl7:observation
R

The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed).

The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations, or which do not allow the negation to be recorded with post-coordinated coded terminology.

6.3.4.14
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1R6.3.4.14
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II1 … 1R6.3.4.14
@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
hl7:id
II1 … 1M6.3.4.14
hl7:code
CD1 … 1R6.3.4.14
hl7:text
ED1 … 1M
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
6.3.4.14
hl7:statusCode
CS0 … 1R

A 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'.

6.3.4.14
@code
CONF0 … 1Fcompleted
hl7:effectiveTime
IVL_TS0 … 1R6.3.4.14
hl7:value
CD1 … *R6.3.4.14
hl7:originalText
0 … 1R

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.

6.3.4.14
hl7:reference
0 … 1R6.3.4.14
hl7:entryRelationship
0 … 1R
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 IHE Severity Entry (DYNAMIC)		6.3.4.14
hl7:entryRelationship
0 … 1R



Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 IHE Problem Status Observation (DYNAMIC)		6.3.4.14
@typeCode
cs1 … 1FREFR
hl7:entryRelationship
0 … 1R
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 IHE Health Status Observation (DYNAMIC)		6.3.4.14
@typeCode
cs1 … 1FREFR