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Template Problem Observation 2015‑12‑06

Id1.2.276.0.76.10.4075Effective Date2015‑12‑06
Statusdraft DraftVersion Label
NameProblemObservationDisplay NameProblem Observation
Description
This template reflects a discrete observation about a patient's problem. Because it is a discrete observation, it will have a statusCode of "completed". The effectiveTime, also referred to as the “biologically relevant time” is the time at which the observation holds for the patient. For a provider seeing a patient in the clinic today, observing a history of heart attack that occurred five years ago, the effectiveTime is five years ago. The effectiveTime of the Problem Observation is the definitive indication of whether or not the underlying condition is resolved. If the problem is known to be resolved, then an effectiveTime/high would be present. If the date of resolution is not known, then effectiveTime/high will be present with a nullFlavor of "UNK".
ContextParent nodes of template element with id 1.2.276.0.76.10.4075
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 6 templates
Used by as NameVersion
1.2.276.0.76.3.1.261.1.10.4.33Containmentdraft Problem Concern Act2018‑10‑18 10:02:10
1.2.276.0.76.10.3023linkdraft Frühere Erkrankungen2017‑04‑09
1.2.276.0.76.10.3079linkdraft Gesundheitsprobleme2017‑03‑01
1.2.276.0.76.10.4074Containmentdraft Problem Concern Act2015‑12‑06
Uses as NameVersion
1.2.276.0.76.10.4076Containmentdraft Priorität PräferenzDYNAMIC
1.2.276.0.76.10.4077Containmentdraft Alter BeobachtungDYNAMIC
1.2.276.0.76.10.4078Containmentdraft Prognose ObservationDYNAMIC
1.2.276.0.76.10.4093Containmentdraft Manifestation ObservationDYNAMIC
1.2.276.0.76.10.4094Containmentdraft Etiology ObservationDYNAMIC
1.2.276.0.76.10.90025Includedraft Author (Body)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 2.16.840.1.113883.10.20.22.4.4 Problem Observation (V3) (2015‑08‑01)
ref
ccda-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <!-- Problem Observation -->
  <templateId root="1.2.276.0.76.10.4075"/>  <id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>  <code code="29308-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Diagnosis"/>  <!-- The statusCode reflects the status of the observation itself -->
  <statusCode code="completed"/>  <effectiveTime>
    <!-- Das low Element gibt das Datum an, seit wann der Patient dieses Problem hat -->
    <low value="20130703"/>    <!-- Das high Element gibt das Datum an, seit wann der Patient dieses Problem nicht mehr hat -->
    <high value="20130721"/>  </effectiveTime>  <!-- Im value Element wird das Problem angegeben. Dies kann ein ICD 10 Code oder ein anderer Code sein. -->
  <value xsi:type="CD" code="J11.1" codeSystem="1.2.276.0.76.5.430" displayName="Grippe mit sonstigen Manifestationen an den Atemwegen, Viren nicht nachgewiesen"/>  <author typeCode="AUT">
    <!-- optional: Autor des Problem -->
  </author></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
Probdotstion
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
hl7:templateId
1 … 1MProbdotstion
@root
uid1 … 1F1.2.276.0.76.10.4075
hl7:id
1 … *Probdotstion
hl7:code
1 … 1MProbdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.2 Problem Type (DYNAMIC)
hl7:statusCode
1 … 1MProbdotstion
@code
CONF1 … 1Fcompleted
hl7:effectiveTime
1 … 1MIf the problem is known to be resolved, but the date of resolution is not known, then the high element SHALL be present, and the nullFlavor attribute SHALL be set to 'UNK'. Therefore, the existence of an high element within a problem does indicate that the problem has been resolved.Probdotstion
hl7:low
1 … 1MThe effectiveTime/low (a.k.a. "onset date") asserts when the condition became biologically active.Probdotstion
hl7:high
0 … 1The effectiveTime/high (a.k.a. "resolution date") asserts when the condition became biologically resolved.Probdotstion
hl7:value
CD1 … 1RProbdotstion
 CONF
shall be drawn from concept domain "Problemcodes"
hl7:qualifier
0 … *This value MAY contain zero or more [0..*] qualifier (CONF:1198-31870).

The observation/value and all the qualifiers together (often referred to as a post-coordinated expression) make up one concept. Qualifiers constrain the meaning of the primary code, and cannot negate it or change its meaning. Qualifiers can only be used according to well-defined rules of post-coordination and only if the underlying code system defines the use of such qualifiers or if there is a third code system that specifies how other code systems may be combined. For example, SNOMED CT allows constructing concepts as a combination of multiple codes. SNOMED CT defines a concept "pneumonia (disorder)" (233604007) an attribute "finding site" (363698007) and another concept "left lower lobe of lung (body structure)" (41224006). SNOMED CT allows one to combine these codes in a code phrase, as shown in the sample XML.		Probdotstion
hl7:translation
0 … *Probdotstion
@code
0 … 1 MAY contain zero or one [0..1] @code (CodeSystem: ICD10CM urn:oid:2.16.840.1.113883.6.90 STATIC) (CONF:1198-16750).
hl7:author
0 … *RProbdotstion
Included from 1.2.276.0.76.10.90025 Author (Body) (DYNAMIC)
@typeCode
cs0 … 1FAUT
@contextControlCode
cs0 … 1FOP
hl7:functionCode
CE0 … 1AuthdotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10267 ParticipationFunction (DYNAMIC)
hl7:time
TS1 … 1RAuthdotsBody
hl7:assignedAuthor
1 … 1RAuthdotsBody
@classCode
cs0 … 1FASSIGNED
hl7:id
II1 … *RAuthdotsBody
hl7:code
CE0 … 1AuthdotsBody
@codeSystem
CONF0 … 1F2.16.840.1.113883.5.111
hl7:addr
AD0 … *AuthdotsBody
hl7:telecom
TEL0 … *AuthdotsBody
hl7:assignedPerson
0 … 1AuthdotsBody
Included from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1MPersdotsents
hl7:representedOrganization
0 … 1AuthdotsBody
Included from 1.2.276.0.76.10.90011 CDA Organization Elements (DYNAMIC)
@classCode
cs0 … 1FORG
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *Orgadotsents
hl7:name
ON1 … 1MOrgadotsents
hl7:telecom
TEL0 … *Orgadotsents
hl7:addr
AD0 … 1Orgadotsents
hl7:entryRelationship
0 … 1de-DE Alter des Patienten
Contains 1.2.276.0.76.10.4077 Alter Beobachtung (DYNAMIC)		Probdotstion
@typeCode
cs1 … 1FSUBJ
@inversionInd
bl1 … 1Ftrue
hl7:entryRelationship
0 … 1de-DE Prognose des Problems
Contains 1.2.276.0.76.10.4078 Prognose Observation (DYNAMIC)		Probdotstion
@typeCode
cs1 … 1FREFR
hl7:entryRelationship
0 … *de-DE Schweregrad des Problems laut Einschätzung des Gesundheitsdienstleisters
Contains 1.2.276.0.76.10.4076 Priorität Präferenz (DYNAMIC)		Probdotstion
@typeCode
cs1 … 1FREFR
hl7:entryRelationship
0 … *de-DE Manifestations-Beobachtung
Contains 1.2.276.0.76.10.4093 Manifestation Observation (DYNAMIC)		Probdotstion
@typeCode
cs1 … 1FMFST
hl7:entryRelationship
0 … *de-DE Ätiologie-Beobachtung
Contains 1.2.276.0.76.10.4094 Etiology Observation (DYNAMIC)		Probdotstion
@typeCode
cs1 … 1FCAUS