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Template Alert observation 2007‑04‑01

Id2.16.840.1.113883.10.20.1.18
ref
ccd1-
Effective Date2007‑04‑01
Statuspending Under pre-publication reviewVersion Label
NameAlertObservationDisplay NameAlert observation
Description
3.8.2.1.2 Alert observation

CONF-262: An alert observation (templateId 2.16.840.1.113883.10.20.1.18) SHALL be represented with Observation.
CONF-263: The value for “Observation / @moodCode” in an alert observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-264: An alert observation SHALL include exactly one Observation / statusCode.
CONF-265: The value for “Observation / statusCode” in an alert observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.
CONF-266: An alert observation MAY contain exactly one Observation / effectiveTime, to indicate the biological timing of condition (e.g. the time the condition started, the onset of the illness or symptom, the duration of a condition).
CONF-267: The value for “Observation / value” in an alert observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.4 AlertTypeCode STATIC 20061017.
CONF-268: The absence of known allergies SHOULD be represented in an alert observation by valuing Observation / value with 160244002 “No known allergies” 2.16.840.1.113883.6.96 SNOMED CT STATIC.
CONF-269: An alert observation SHALL contain one or more sources of information, as defined in section 5.2 Source.

3.8.2.3 Representation of agent

The agent indicates the entity that is the cause of the allergy or adverse reaction. While the agent is often implicit in the alert observation (e.g. “allergy to penicillin”), it should also be asserted explicitly as an entity.

NOTE: The agent responsible for an allergy or adverse reaction is not always a manufactured material, 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.

CONF-273: An alert observation SHOULD contain at least one Observation / participant, representing the agent that is the cause of the allergy or adverse reaction.
CONF-274: An agent participation in an alert observation SHALL contain exactly one participant / participantRole / playingEntity.
CONF-275: The value for Observation / participant / @typeCode in an agent participation SHALL be “CSM” “Consumable” 2.16.840.1.113883.5.90 ParticipationType STATIC.
CONF-276: The value for Observation / participant / participantRole / @classCode in an agent participation SHALL be “MANU” “Manufactured” 2.16.840.1.113883.5.110 RoleClass STATIC.
CONF-277: The value for Observation / participant / participantRole / playingEntity / @classCode in an agent participation SHALL be “MMAT” “Manufactured material” 2.16.840.1.113883.5.41 EntityClass STATIC.
CONF-278: An agent participation in an alert observation SHALL contain exactly one participant / participantRole / playingEntity / code.
CONF-279: The value for “participant / participantRole / playingEntity / code” in an agent participation SHOULD be selected from the RxNorm (2.16.840.1.113883.6.88) code system for medications, and from the CDC Vaccine Code (2.16.840.1.113883.6.59) code system for immunizations .

3.8.2.4 Reaction observations and interventions

The template identifier for a reaction observation is 2.16.840.1.113883.10.20.1.54.
The template identifier for a severity observation is 2.16.840.1.113883.10.20.1.55.

A reaction represents an adverse event due to an administered or exposed substance. A reaction can be defined with respect to its severity, and can have been treated by one or more interventions.

CONF-280: An alert observation MAY contain one or more reaction observations (templateId 2.16.840.1.113883.10.20.1.54), each of which MAY contain exactly one severity observation (templateId 2.16.840.1.113883.10.20.1.55) AND/OR one or more reaction interventions.
CONF-281: The value for “entryRelationship / @typeCode” in a relationship between an alert observation and reaction observation SHALL be “MFST” “Is manifestation of” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC.

3.8.2.4.1.1 Reaction observation

CONF-282: A reaction observation (templateId 2.16.840.1.113883.10.20.1.54) SHALL be represented with Observation.
CONF-283: The value for “Observation / @classCode” in a reaction observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-284: The value for “Observation / @moodCode” in a reaction observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-285: A reaction observation SHALL include exactly one Observation / statusCode.
CONF-286: The value for “Observation / statusCode” in a reaction observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.

3.8.2.4.1.2 Severity observation

CONF-287: A severity observation (templateId 2.16.840.1.113883.10.20.1.55) SHALL be represented with Observation.
CONF-288: The value for “entryRelationship / @typeCode” in a relationship between a reaction observation and severity observation SHALL be “SUBJ” “Has subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC.
CONF-289: The value for “Observation / @classCode” in a severity observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
CONF-290: The value for “Observation / @moodCode” in a severity observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
CONF-291: A severity observation SHALL include exactly one Observation / statusCode.
CONF-292: The value for “Observation / statusCode” in a severity observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.
CONF-293: A severity observation SHALL contain exactly one Observation / code.
CONF-294: The value for “Observation / code” in a severity observation SHALL be “SEV” “Severity observation” 2.16.840.1.113883.5.4 ActCode STATIC.
CONF-295: A severity observation SHALL contain exactly one Observation / value.

3.8.2.4.1.3 Reaction intervention

CONF-296: The value for “entryRelationship / @typeCode” in a relationship between a reaction observation and reaction intervention SHALL be “RSON” “Has reason” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC.
CONF-297: A reaction intervention SHALL be represented as a procedure activity (templateId 2.16.840.1.113883.10.20.1.29), a medication activity (templateId 2.16.840.1.113883.10.20.1.24), or some other clinical statement.

ContextParent nodes of template element with id 2.16.840.1.113883.10.20.1.18
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 21 templates, Uses 5 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.777.4.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.777.4.10.50linkpending Procedure activity (act)2007‑04‑01
2.16.840.1.113883.3.1937.777.4.10.51linkpending Procedure activity (observation)2007‑04‑01
2.16.840.1.113883.3.1937.777.4.10.52linkpending Procedure activity (procedure)2007‑04‑01
2.16.840.1.113883.10.20.1linkpending CCD v1.0 Templates Root2007‑04‑01
2.16.840.1.113883.10.20.1.2linkpending Alerts section2007‑04‑01
2.16.840.1.113883.10.20.1.5linkpending Functional status section2007‑04‑01
2.16.840.1.113883.10.20.1.6linkpending Immunization section2007‑04‑01
2.16.840.1.113883.10.20.1.7linkpending Medical equipment section2007‑04‑01
2.16.840.1.113883.10.20.1.8linkpending Medication section2007‑04‑01
2.16.840.1.113883.10.20.1.11linkpending Problem section2007‑04‑01
2.16.840.1.113883.10.20.1.12linkpending Procedures section2007‑04‑01
2.16.840.1.113883.10.20.1.14linkpending Results section2007‑04‑01
2.16.840.1.113883.10.20.1.15linkpending Social history section2007‑04‑01
2.16.840.1.113883.10.20.1.16linkpending Vital signs section2007‑04‑01
2.16.840.1.113883.10.20.1.18linkpending Alert observation2007‑04‑01
2.16.840.1.113883.10.20.1.24linkpending Medication activity2007‑04‑01
2.16.840.1.113883.10.20.1.27Includepending Problem act2007‑04‑01
2.16.840.1.113883.10.20.1.32linkpending Result organizer2007‑04‑01
2.16.840.1.113883.10.20.1.33linkpending Social history observation2007‑04‑01
2.16.840.1.113883.10.20.1.35linkpending Vital signs organizer2007‑04‑01
2.16.840.1.113883.10.20.1.41linkpending Episode observation2007‑04‑01
Uses as NameVersion
2.16.840.1.113883.3.1937.777.4.10.3Containmentpending CCD Subject (Body)DYNAMIC
2.16.840.1.113883.3.1937.777.4.10.20Containmentpending CCD Informant (Body)DYNAMIC
2.16.840.1.113883.10.20.1.39Containmentpending Alert status observationDYNAMIC
2.16.840.1.113883.10.20.1.40Containmentpending CommentDYNAMIC
2.16.840.1.113883.10.20.1.54Containmentpending Reaction observationDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:observation
CONF‑262
@classCode
cs0 … 1 
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.11529 ActClassObservation (DYNAMIC)
@moodCode
cs1 … 1FEVNCONF‑263
@negationInd
bl0 … 1 
 Schematron assertroleorange warning 
 testhl7:informant or hl7:reference[@typeCode='XCRPT'] or hl7:entryRelationship[@typeCode='REFR']/hl7:observation[@classCode='OBS'][@moodCode='EVN'][hl7:statusCode/@code='completed'][hl7:code[@code='48766-0'][@codeSystem='2.16.840.1.113883.6.1'][@displayName='Information source']][hl7:value] 
 MessageCONF-269: A alert observation SHALL contain one or more sources of information, as defined in section 5.2 Source. 
hl7:templateId
II1 … 1CONF‑262
@root
uid1 … 1F2.16.840.1.113883.10.20.1.18
hl7:id
II0 … *CONF‑262
hl7:code
CD1 … 1RCONF‑262
 CONF
shall be drawn from concept domain "ObservationType"
hl7:derivationExpr
ST0 … 1CONF‑262
hl7:text
ED0 … 1CONF‑262
hl7:statusCode
CS1 … 1MCONF‑264 / CONF‑265
@code
CONF1 … 1Fcompleted
hl7:effectiveTime
IVL_TS0 … 1CONF‑266
hl7:priorityCode
CE0 … 1CONF‑262
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
hl7:repeatNumber
IVL_INT0 … 1CONF‑262
hl7:languageCode
CS0 … 1CONF‑262
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:value
0 … 1CONF‑267 / CONF‑268
hl7:interpretationCode
CE0 … *CONF‑262
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
hl7:methodCode
CE0 … *CONF‑262
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
hl7:targetSiteCode
CD0 … *CONF‑262
 CONF
shall be drawn from concept domain "ActSite"
hl7:subject
0 … 1Contains 2.16.840.1.113883.3.1937.777.4.10.3 CCD Subject (Body) (DYNAMIC)CONF‑262
hl7:informant
0 … *Contains 2.16.840.1.113883.3.1937.777.4.10.20 CCD Informant (Body) (DYNAMIC)CONF‑269
hl7:participant
1 … *CONF‑273
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.10901 ParticipationType (DYNAMIC)
@contextControlCode
cs0 … 1FOP
hl7:time
IVL_TS0 … 1CONF‑273
hl7:awarenessCode
CE0 … 1CONF‑273
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.10310 TargetAwareness (DYNAMIC)
hl7:participantRole
1 … 1CONF‑274
@classCode
cs1 … 1FMANUCONF‑276
hl7:id
II0 … *CONF‑274
hl7:code
CE0 … 1CONF‑274
 CONF
shall be drawn from concept domain "RoleCode"
hl7:addr
AD0 … *CONF‑274
hl7:telecom
TEL0 … *CONF‑274
hl7:playingEntity
1 … 1CONF‑274
@classCode
cs1 … 1FMMATCONF‑277
@determinerCode
cs0 … 1FINSTANCE
hl7:code
CE1 … 1CONF‑278 / CONF‑279
 CONF
@codeSystem shall be "2.16.840.1.113883.6.88"
or
@codeSystem shall be "2.16.840.1.113883.6.59"
hl7:quantity
PQ0 … *CONF‑274
hl7:name
PN0 … *CONF‑274
hl7:desc
ED0 … 1CONF‑274
hl7:scopingEntity
0 … 1CONF‑274
@classCode
cs0 … 1 
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.10882 EntityClass (DYNAMIC)
@determinerCode
cs0 … 1FINSTANCE
hl7:id
II0 … *CONF‑274
hl7:code
CE0 … 1CONF‑274
 CONF
shall be drawn from concept domain "EntityCode"
hl7:desc
ED0 … 1CONF‑274
hl7:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.1.39 Alert status observation (DYNAMIC)CONF‑270
@typeCode
cs1 … 1FREFRCONF‑509
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑270
hl7:seperatableInd
BL0 … 1CONF‑270
hl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.1.54 Reaction observation (DYNAMIC)CONF‑280
@typeCode
cs1 … 1FMFSTCONF‑281
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑280
hl7:seperatableInd
BL0 … 1CONF‑280
hl7:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.1.40 Comment (DYNAMIC)CONF‑502
@typeCode
cs1 … 1R
 CONF
The value of @typeCode shall be drawn from value set 2.16.840.1.113883.1.11.19447 x_ActRelationshipEntryRelationship (DYNAMIC)
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑502
hl7:seperatableInd
BL0 … 1CONF‑502
hl7:entryRelationship
0 … *CONF‑269
@typeCode
cs1 … 1FREFRCONF‑524
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑269
hl7:seperatableInd
BL0 … 1CONF‑269
hl7:observation
1 … 1CONF‑523 / CONF‑525
@classCode
cs0 … 1 CONF‑526
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.11529 ActClassObservation (DYNAMIC)
@moodCode
cs1 … 1FEVNCONF‑527
hl7:code
CD1 … 1MCONF‑530 / CONF‑531
@code
CONF1 … 1F48766-0
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@displayName
1 … 1FInformation source
hl7:statusCode
CS1 … 1MCONF‑528 / CONF‑529
@code
CONF1 … 1Fcompleted
hl7:value
1 … 1MCONF‑532 / CONF‑533
hl7:reference
0 … *CONF‑269
where [@typeCode='XCRPT']
hl7:referenceRange
0 … *CONF‑262
@typeCode
cs0 … 1FREFV
hl7:observationRange
1 … 1CONF‑262
@classCode
cs0 … 1 
 CONF
The value of @classCode shall be drawn from value set 2.16.840.1.113883.1.11.11529 ActClassObservation (DYNAMIC)
@moodCode
cs0 … 1 
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.1.11.20268 ActMoodEventCriterion (DYNAMIC)
hl7:code
CD0 … 1CONF‑262
 CONF
shall be drawn from concept domain "ActCode"
hl7:text
ED0 … 1CONF‑262
hl7:value
0 … 1CONF‑262
hl7:interpretationCode
CE0 … 1CONF‑262
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)