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Template Allergie/Unverträglichkeit Observation 2017‑06‑04

Id1.2.276.0.76.10.4257Effective Date2017‑06‑04
Statusdraft DraftVersion Label
NameAllergyintoleranceobservationDisplay NameAllergie/Unverträglichkeit Observation
ContextParent nodes of template element with id 1.2.276.0.76.10.4257
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 4 templates
Used by as NameVersion
1.2.276.0.76.10.4256Containmentdraft Allergie/Unverträglichkeit Concern Act2017‑06‑04
Uses as NameVersion
1.2.276.0.76.10.4258Containmentdraft Reaktion/ManifestationDYNAMIC
1.2.276.0.76.10.4259Containmentdraft KritikalitätDYNAMIC
1.2.276.0.76.10.90020Includedraft RelatedEntity (Body)DYNAMIC
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 2.16.840.1.113883.10.20.22.4.7 Allergy - Intolerance Observation (V2) (2014‑06‑09)
ref
ccda-
Example
Antibiotika-Allergie bekannt seit 2010
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4257"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>  <code code="OINT" codeSystem="2.16.840.1.113883.5.4" displayName="adverse reaction upon exposure to an agent"/>  <statusCode code="completed"/>  <effectiveTime>
    <low value="2010"/>  </effectiveTime>  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code="A07AA" codeSystem="2.16.840.1.113883.6.73" displayName="Antibiotikum">
          <originalText>
            <reference value="#alg-1"/>          </originalText>        </code>      </playingEntity>    </participantRole>  </participant></observation>
Example
Keine Kontrastmittel-Allergie/Unverträglichkeit bekannt (negationInd=true)
<observation classCode="OBS" moodCode="EVN" negationInd="true">
  <templateId root="1.2.276.0.76.10.4257"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>  <code code="OINT" codeSystem="2.16.840.1.113883.5.4" displayName="adverse reaction upon exposure to an agent"/>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA"/>  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code="V08" codeSystem="2.16.840.1.113883.6.73" displayName="Kontrastmittel">
          <originalText>
            <reference value="#alg-2"/>          </originalText>        </code>      </playingEntity>    </participantRole>  </participant></observation>
Example
Sonstige Allergie: Hühnereiweiss (Der Freitext steht im zugehörigen Section.text, hier referenziert durch #alg-4)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4257"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>  <code code="OINT" codeSystem="2.16.840.1.113883.5.4" displayName="adverse reaction upon exposure to an agent"/>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA"/>  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code nullFlavor="OTH">
          <originalText>
            <reference value="#alg-4"/>          </originalText>        </code>      </playingEntity>    </participantRole>  </participant></observation>
Example
Allergie: ja, Allergen nicht näher bezeichnet (im zugehörigen Section.text, hier referenziert durch #alg-4, kann der Text 'ja, n.n.b.' o.ä. wiedergegeben werden)
<observation classCode="OBS" moodCode="EVN">
  <templateId root="1.2.276.0.76.10.4257"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="55dc1020-7b14-11db-9fe1-0800200c9aab"/>  <code code="OINT" codeSystem="2.16.840.1.113883.5.4" displayName="adverse reaction upon exposure to an agent"/>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA"/>  <participant typeCode="CSM">
    <participantRole classCode="MANU">
      <playingEntity classCode="MMAT">
        <code code="ALGN" codeSystem="1.2.276.0.76.3.1.195.5.52" displayName="Allergen">
          <originalText>
            <reference value="#alg-4"/>          </originalText>        </code>      </playingEntity>    </participantRole>  </participant></observation>
Example
Keine Allergie/Unverträglichkeit bekannt (negationInd=true)
<observation classCode="OBS" moodCode="EVN" negationInd="true">
  <templateId root="1.2.276.0.76.10.4257"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>  <code code="OINT" codeSystem="2.16.840.1.113883.5.4" displayName="adverse reaction upon exposure to an agent"/>  <statusCode code="completed"/>  <!-- N/A - author/time records when this assertion was made -->
  <effectiveTime nullFlavor="NA"/></observation>
Example
Allergie/Unverträglichkeit nicht erfragt (nullFlavor=NASK)
<observation classCode="OBS" moodCode="EVN" nullFlavor="NASK">
  <templateId root="1.2.276.0.76.10.4257"/>  <id root="1.2.276.0.76.4.17.9814184919" extension="4adc1020-7b14-11db-9fe1-0800200c9a66"/>  <code code="OINT" codeSystem="2.16.840.1.113883.5.4" displayName="adverse reaction upon exposure to an agent"/>  <statusCode code="completed"/>  <!-- N/A - author/time records when this assertion was made -->
  <effectiveTime nullFlavor="NA"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
Alledotstion
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
@negationInd
bl0 … 1 
@nullFlavor
cs0 … 1 
 CONF
@nullFlavor shall be "NASK"
hl7:templateId
II1 … 1MAlledotstion
@root
uid1 … 1F1.2.276.0.76.10.4257
hl7:id
II1 … *MAlledotstion
hl7:code
CV1 … 1MAlledotstion
 CONF
@code shall be "ALG"
@codeSystem shall be "2.16.840.1.113883.5.4"
or
@code shall be "OINT"
@codeSystem shall be "2.16.840.1.113883.5.4"
hl7:statusCode
CS1 … 1MAlledotstion
hl7:effectiveTime
IVL_TS1 … 1RAlledotstion
hl7:low
TS0 … 1RAlledotstion
hl7:high
TS0 … 1RAlledotstion
hl7:value
CD0 … 1Cde-DE Code für die Allergie/IntoleranzAlledotstion
 CONF
The value of @code shall be drawn from value set 1.2.276.0.76.11.12 Allergien und Unverträglichkeiten (DYNAMIC)
Choice0 … 1
de-DE Angabe, woher die Information zur Allergie oder Unverträglichkeit des Patienten stammt
Elements to choose from:
  • hl7:author
  • hl7:informant[hl7:relatedEntity]
  • hl7:participant[@typeCode='AUT']
hl7:author
de-DE Autor dieser Information ist ein GesundheitsdienstleisterAlledotstion
 Example
Autor der Information ist ein Gesundheitsdienstleister
<author>
  <time value="20131221"/>  <assignedAuthor>
    <id root="1.2.276.0.76.4.16" extension="123456701"/>    <assignedPerson>
      <name>
        <given qualifier="IN">Jan H.</given>        <family>Ausarz</family>      </name>    </assignedPerson>  </assignedAuthor></author>
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:informant
0 … 1de-DE Informant dieser Information ist eine Kontaktperson/Angehöriger des PatientenAlledotstion
@typeCode
cs0 … 1FINF
@contextControlCode
cs0 … 1FOP
 Example
Informant dieser Information ist eine Kontaktperson/Angehöriger des Patienten
<informant>
  <relatedEntity classCode="CON">
    <relatedPerson classCode="PSN" determinerCode="INSTANCE">
      <name> ... </name>    </relatedPerson>  </relatedEntity></informant>
hl7:relatedEntity
1 … 1MAlledotstion
Included from 1.2.276.0.76.10.90020 RelatedEntity (Body) (DYNAMIC)
@classCode
cs1 … 1R
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.19316 RoleClassMutualRelationship (DYNAMIC)
hl7:code
CE0 … 1ReladotsBody
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.19563 PersonalRelationshipRoleType (DYNAMIC)
hl7:addr
AD0 … *ReladotsBody
hl7:telecom
TEL0 … *ReladotsBody
hl7:effectiveTime
IVL_TS0 … 1ReladotsBody
hl7:relatedPerson
0 … 1ReladotsBody
Included from 1.2.276.0.76.10.90010 CDA Person Elements (DYNAMIC)
@classCode
cs0 … 1FPSN
@determinerCode
cs0 … 1FINSTANCE
hl7:name
PN1 … 1MPersdotsents
hl7:participant
de-DE Autor dieser Information ist der PatientAlledotstion
where [@typeCode='AUT']
@typeCode
cs1 … 1FAUT
 Example
Autor der Information ist der Patient
<participant typeCode="AUT">
  <participantRole classCode="PAT"/></participant>
hl7:time
TS0 … 1RAlledotstion
hl7:participantRole
1 … 1MAlledotstion
@classCode
cs1 … 1FPAT
hl7:participant
0 … 1CAlledotstion
where [@typeCode='CSM']
@typeCode
cs1 … 1FCSM
hl7:participantRole
1 … 1MAlledotstion
@classCode
cs1 … 1FMANU
hl7:playingEntity
1 … 1MAlledotstion
@classCode
cs1 … 1FMMAT
hl7:code
CE1 … 1Rde-DE Auslösendes Agens: Substanzen (ATC)Alledotstion
@codeSystem
CONF0 … 1F2.16.840.1.113883.6.73
 Schematron assertrolered error 
 testhl7:value[@code] or hl7:participant/hl7:participantRole 
 MessageWenn das observation/value Element und mit einem Code versehen ist, dann MUSS das observation/participant Element weggelassen werden 
hl7:entryRelationship
0 … *RContains 1.2.276.0.76.10.4258 Reaktion/Manifestation (DYNAMIC)Alledotstion
@typeCode
cs1 … 1FMFST
hl7:entryRelationship
0 … 1RContains 1.2.276.0.76.10.4259 Kritikalität (DYNAMIC)Alledotstion
@typeCode
cs1 … 1FSUBJ