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Template Allergies And Intolerances 2013‑12‑20

Id1.3.6.1.4.1.19376.1.5.3.1.4.6Effective Date2013‑12‑20
Statusdraft DraftVersion Label
NameEntryAllergyAndIntoleranceDisplay NameAllergies And Intolerances
Description

Allergies and intolerances are special kinds of problems, and so are also recorded in the CDA <observation> element, with classCode='OBS'. They follow the same pattern as the problem entry, with exceptions noted below.

Parent Template

This is a specialization of the IHE PCC Problem Entry 1.3.6.1.4.1.19376.1.5.3.1.4.5 and of the CCD alert observation template 2.16.840.1.113883.10.20.1.18

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.6
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Associated with
Associated with 3 concepts
IdNameData Set
epsos-dataelement-70draft Onset Date draft epSOS Data Set
epsos-dataelement-68draft Allergy description draft epSOS Data Set
epsos-dataelement-69draft Allergy code draft epSOS Data Set
Used by / Uses
Used by 8 transactions and 23 templates, Uses 3 templates
Used by as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.4.9Transactiondraft IHE Emergency Department Referral2017‑03‑30 09:26:33
1.3.6.1.4.1.19376.1.5.3.1.4.10Transactiondraft IHE Discharge Summary2017‑03‑30 09:27:43
1.3.6.1.4.1.19376.1.5.3.1.4.12Transactiondraft IHE PHR Extract2017‑03‑30 09:29:02
1.3.6.1.4.1.19376.1.5.3.1.4.11Transactiondraft IHE Immunization Content2017‑03‑30 09:28:26
2.16.840.1.113883.3.1937.777.11.4.12Transactiondraft Return PS of country A2012‑05‑02
2.16.840.1.113883.3.1937.777.11.4.23Transactiondraft Return MRO2013‑11‑02
2.16.840.1.113883.3.1937.777.11.4.21Transactiondraft Send HCER to country A2013‑11‑02
1.3.6.1.4.1.19376.1.5.3.1.4.4Transactiondraft IHE Referral Summary2016‑09‑29 13:42:51
1.3.6.1.4.1.12559.11.10.1.3.1.1.3linkdraft epSOS-Patient Summary2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3linkretired epSOS-Patient Summary2018‑11‑14 10:53:50
1.3.6.1.4.1.12559.11.10.1.3.1.1.3linkretired eHDSI Patient Summary2020‑04‑14 13:03:47
1.3.6.1.4.1.12559.11.10.1.3.1.1.4linkdraft epSOS-Health Care Encounter Report2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4linkretired epSOS-Health Care Encounter Report2018‑11‑14 09:02:41
1.3.6.1.4.1.12559.11.10.1.3.1.1.5linkdraft epSOS-Medication Related Overview2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5linkretired epSOS-Medication Related Overview2018‑11‑14 09:03:13
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
1.3.6.1.4.1.19376.1.5.3.1.3.13linkdraft Section Allergies and Other Adverse Reactions2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13linkretired Section Allergies and Other Adverse Reactions2019‑04‑05 14:39:26
1.3.6.1.4.1.19376.1.5.3.1.3.13linkretired Section Allergies and Other Adverse Reactions2019‑04‑05 14:39:34
1.3.6.1.4.1.19376.1.5.3.1.3.13linkretired eHDSI Allergies and Other Adverse Reactions2020‑04‑16 11:58:56
1.3.6.1.4.1.19376.1.5.3.1.4.5.3Containmentdraft Allergy and Intolerance Concern2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3Containmentretired Allergy and Intolerance Concern2019‑04‑08 13:59:03
1.3.6.1.4.1.19376.1.5.3.1.4.5.3Containmentretired eHDSI Allergy And Intolerance Concern2020‑04‑16 12:30:31
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
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
1.3.6.1.4.1.19376.1.5.3.1.4.1Containmentdraft SeverityDYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.5Containmentdraft ProblemDYNAMIC
2.16.840.1.113883.3.1937.777.11.10.134Containmentdraft CDA Participant (Body)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.20.1.18 (DYNAMIC)
Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC)
Example
Example
<observation classCode="OBS" moodCode="EVN" negationInd="false">
  <templateId root="2.16.840.1.113883.10.20.1.18"/>  <templateId root="2.16.840.1.113883.10.20.1.28"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>  <id root=" " extension=" "/>  <!-- This is the code that shows what kind of allergy or intolerance derived from the epSOSAdverseEventType Value Set-->
  <code code="" codeSystem="2.16.840.1.113883.6.96"/>  <text>
    <reference value=" "/>  </text>  <statusCode code="completed"/>  <effectiveTime>
    <low value=" "/>    <high value=" "/>  </effectiveTime>  <!-- value element is present only to indicate no known allergies, in all other cases is used for referenicng text in the narrative -->
  <value xsi:type="CD"/>  <!-- This is the allergen - the substance that caused the allergy -->
  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code=" " codeSystem=" ">
          <originalText>
            <reference value="#substance"/>          </originalText>        </code>        <name/>      </playingEntity>    </participantRole>  </participant>  <!-- This is how the allergy manifests itself -->
  <entryRelationship typeCode="MFST">
    <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.6.1"/>    <!-- a problem entry -->
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.54"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>      <!-- The code tells us that the observation is a symptom -->
      <code code="418799008" codeSystem="2.16.840.1.113883.6.96" displayName="Finding reported by subject or history provider" codeSystemName="SNOMED CT"/>      <text>
        <reference value="#manifest-1"/>      </text>      <statusCode code="completed"/>      <!-- The value tells us what the symptom (i.e. allergy manifestation) is -->
      <!-- This is where anaphylaxy or angiooedema will be coded -->
      <value xsi:type="CD" code=" " codeSystem=" " displayName=" " codeSystemName=" "/>    </observation>  </entryRelationship>  <!-- This is how the severity of the allergy is described (Optional)-->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>      <!-- This code is from HL7 and indicates that the observation is about severity -->
      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>      <text>
        <reference value="#severity-1"/>      </text>      <statusCode code="completed"/>      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value xsi:type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>    </observation>  </entryRelationship></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
R

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.6, and is a subtype of the Problem Entry, and so must also conform to the rules of the problem entry, which has the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5. These elements are required and shall be recorded exactly as shown above.

Note: the 1.3.6.1.4.1.19376.1.5.3.1.4.5 requires that also the template ID '2.16.840.1.113883.10.20.1.28' is included.

Entrdotsance
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
II.EPSOS1 … 1RIHE PCC Problem EntryEntrdotsance
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II.EPSOS1 … 1RCCD Alert ObservationEntrdotsance
@root
uid1 … 1F2.16.840.1.113883.10.20.1.18
hl7:templateId
II.EPSOS1 … 1REntrdotsance
@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
hl7:templateId
II.EPSOS1 … 1REntrdotsance
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.6
hl7:id
II.EPSOS0 … *REntrdotsance
hl7:code
CD1 … 1R

The <code> element represents the kind of allergy observation made, to a drug, food or environmental agent, and whether it is an allergy, non-allergy intolerance, or unknown class of intolerance (not known to be allergy or intolerance). The <code> element of an allergy entry shall be provided, and a code and codeSystem attribute shall be present.

Entrdotsance
 
target
epsos-dataelement-69draft Allergy code draft epSOS Data Set
 CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.18 epSOSAdverseEventType (DYNAMIC)
hl7:text
ED1 … 1REntrdotsance
 
target
epsos-dataelement-68draft Allergy description draft epSOS Data Set
hl7:reference
TEL1 … 1MEntrdotsance
@value
1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS1 … 1REntrdotsance
@code
CONF0 … 1Fcompleted
hl7:effectiveTime
IVL_TS0 … 1REntrdotsance
 
target
epsos-dataelement-70draft Onset Date draft epSOS Data Set
hl7:value
CD0 … *R

The value element shall be present in a coded or uncoded form. In both cases the type shall be set to xsi:type='CD'. The coded form shall be used to indicate "No known allergy" (code='716186003' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'). In all other cases it shall be in its uncoded form and may contain a <reference> to the <originalText> in the narrative where the allergy is described.

Entrdotsance
hl7:participant
0 … *C

The substance that causes the allergy or intolerance shall be specified in the <participant> structure.

The <code> element shall be present. It may contain a code and codeSystem attribute to indicate the code for the substance causing the allergy or intolerance. It shall contain a <reference> to the <originalText> in the narrative where the substance is named.


Contains 2.16.840.1.113883.3.1937.777.11.10.134 CDA Participant (Body) (DYNAMIC)		Entrdotsance
 ConstraintConditional: Omit if Observation.value is SNOMED-CT 716186003 No known allergy
hl7:entryRelationship
0 … *R

An allergy entry can record the reactions that are manifestations of the allergy or intolerance as shown below. It uses a related entry (<entryRelationship>) that indicates the manifestations (typeCode='MFST') the reported allergy or intolerance. These are events that may occur, or have occurred in the past as a reaction to the allergy or intolerance<entryRelationship typeCode='MFST'>

The entry contained with this entry relationship is some sort of problem that is a manifestation of the allergy. It is recorded using the Problem Entry structure.

Note: the 1.3.6.1.4.1.19376.1.5.3.1.4.5 requires that also the template ID '2.16.840.1.113883.10.20.1.28' is included.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5 Problem (DYNAMIC)		Entrdotsance
hl7:entryRelationship
0 … 1R

An optional <entryRelationship> element may be present indicating the severity of the problem. If present, this <entryRelationship> element shall contain a severity observation conforming to the Severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1).

The related statement is made about the severity of the condition, concern, or allergy). This observation is recorded inside an <entryRelationship> element occurring in the containing entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

The related statement is another event (moodCode='EVN') observing (<observation classCode='OBS'>) the severity of the (surrounding) related entry (e.g., a condition or allergy).


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 Severity (DYNAMIC)		Entrdotsance
 Example<!-- The encompasing condition or allergy observation -->
<observation classCode="COND" moodCode="EVN">
  <!-- ... -->
  <entryRelationship typeCode="SUBJ" inversionInd="true">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.1.55"/>      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1"/>      <code code="SEV" displayName="Severity" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>      <text>
        <reference value="#severity-2"/>      </text>      <statusCode code="completed"/>      <!-- This code is from SNOMED, according to the epSOS value set-->
      <value xsi:type="CD" code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/>    </observation>  </entryRelationship>  <!-- ... -->
</observation>