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Template Problem observation 2007‑04‑01

Id2.16.840.1.113883.10.20.1.28
ref
ccd1-
Effective Date2007‑04‑01
Statuspending Under pre-publication reviewVersion Label
NameProblemObservationDisplay NameProblem observation
Description

CONF-128: A problem observation or result observation in the functional status section SHALL contain exactly one observation / code.
CONF-135: A problem observation or result observation in the functional status section MAY use codes from the International Classification of Functioning, Disability, and Health (ICF, http://www.who.int/classifications/icf/en/) (codeSystem 2.16.840.1.113883.6.254).
CONF-136: A problem observation in the functional status section SHALL contain exactly one status of functional status observation.

...

3.5.2.1.2 Problem observation

CONF-154: A problem observation (templateId 2.16.840.1.113883.10.20.1.28) SHALL be represented with Observation. CONF-155: The value for “Observation / @moodCode” in a problem observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC. CONF-156: A problem observation SHALL include exactly one Observation / statusCode. CONF-157: The value for “Observation / statusCode” in a problem observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC. CONF-158: A problem observation SHOULD 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-159: The value for “Observation / code” in a problem observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.14 ProblemTypeCode STATIC 20061017. CONF-160: The value for “Observation / entryRelationship / @typeCode” in a problem observation MAY be “SUBJ” “Subject” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC to reference an age observation (templateId 2.16.840.1.113883.10.20.1.38). CONF-161: A problem observation SHALL contain one or more sources of information, as defined in section 5.2 Source.

ContextParent nodes of template element with id 2.16.840.1.113883.10.20.1.28
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 22 templates, Uses 8 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
2.16.840.1.113883.3.1937.777.4.10.50Includepending Procedure activity (act)2007‑04‑01
2.16.840.1.113883.3.1937.777.4.10.51Includepending Procedure activity (observation)2007‑04‑01
2.16.840.1.113883.3.1937.777.4.10.52Includepending 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
2.16.840.1.113883.10.20.1.5Includepending 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
2.16.840.1.113883.10.20.1.54linkpending Reaction 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
2.16.840.1.113883.10.20.1.38Containmentpending Age observationDYNAMIC
2.16.840.1.113883.10.20.1.40Containmentpending CommentDYNAMIC
2.16.840.1.113883.10.20.1.44Containmentpending Status of functional status observationDYNAMIC
2.16.840.1.113883.10.20.1.48Containmentpending Patient awarenessDYNAMIC
2.16.840.1.113883.10.20.1.50Containmentpending Problem status observationDYNAMIC
2.16.840.1.113883.10.20.1.51Containmentpending Problem healthstatus observationDYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
hl7:observation
Probdotstion
@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‑155
@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-161: A problem observation SHALL contain one or more sources of information, as defined in section 5.2 Source. 
 Schematron assertrolered error 
 test(not(hl7:entryRelationship[hl7:observation/hl7:templateId/@root='2.16.840.1.113883.10.20.1.44']) or ancestor::hl7:section[hl7:templateId/@root='2.16.840.1.113883.10.20.1.5']) and (not(ancestor::hl7:section[hl7:templateId/@root='2.16.840.1.113883.10.20.1.5']) or hl7:entryRelationship[hl7:observation/hl7:templateId/@root='2.16.840.1.113883.10.20.1.44']) 
 MessageCONF-136: A problem observation in the functional status section SHALL contain exactly one status of functional status observation. 
hl7:templateId
II1 … 1Probdotstion
@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
hl7:id
II0 … *Probdotstion
hl7:code
CD1 … 1R

CONF-129: The value for “Observation / code” in a problem observation or result observation in the functional status section MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.6 FunctionalStatusTypeCode STATIC 20061017.
CONF-159: The value for “Observation / code” in a problem observation MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.14 ProblemTypeCode STATIC 20061017.

CONF‑128
hl7:derivationExpr
ST0 … 1Probdotstion
hl7:text
ED0 … 1Probdotstion
hl7:statusCode
CS1 … 1MCONF‑156 / CONF‑157
@code
CONF1 … 1Fcompleted
hl7:effectiveTime
IVL_TS1 … 1RProbdotstion
hl7:priorityCode
CE0 … 1Probdotstion
 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 … 1Probdotstion
hl7:languageCode
CS0 … 1Probdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.11526 HumanLanguage (DYNAMIC)
hl7:value
0 … *Probdotstion
hl7:interpretationCode
CE0 … *Probdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)
hl7:methodCode
CE0 … *Probdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.14079 ObservationMethod (DYNAMIC)
hl7:targetSiteCode
CD0 … *Probdotstion
 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)Probdotstion
hl7:informant
0 … *Contains 2.16.840.1.113883.3.1937.777.4.10.20 CCD Informant (Body) (DYNAMIC)CONF‑161
hl7:participant
0 … 1Contains 2.16.840.1.113883.10.20.1.48 Patient awareness (DYNAMIC)CONF‑178 / CONF‑179 / CONF‑180
hl7:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.1.44 Status of functional status observation (DYNAMIC)CONF‑136
@typeCode
cs1 … 1FREFRCONF‑509
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑136
hl7:seperatableInd
BL0 … 1CONF‑136
hl7:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.1.38 Age observation (DYNAMIC)CONF‑160
@typeCode
cs1 … 1FSUBJCONF‑160
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑160
hl7:seperatableInd
BL0 … 1CONF‑160
hl7:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.1.50 Problem status observation (DYNAMIC)CONF‑162
@typeCode
cs1 … 1FREFRCONF‑509
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑162
hl7:seperatableInd
BL0 … 1CONF‑162
hl7:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.1.51 Problem healthstatus observation (DYNAMIC)CONF‑165
@typeCode
cs1 … 1FREFRCONF‑509
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑165
hl7:seperatableInd
BL0 … 1CONF‑165
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‑161
@typeCode
cs1 … 1FREFRCONF‑524
@contextConductionInd
bl0 … 1 
@inversionInd
bl0 … 1 
@negationInd
bl0 … 1 
hl7:sequenceNumber
INT0 … 1CONF‑161
hl7:seperatableInd
BL0 … 1CONF‑161
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‑161
where [@typeCode='XCRPT']
hl7:referenceRange
0 … *Probdotstion
@typeCode
cs0 … 1FREFV
hl7:observationRange
1 … 1Probdotstion
@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 … 1Probdotstion
 CONF
shall be drawn from concept domain "ActCode"
hl7:text
ED0 … 1Probdotstion
hl7:value
0 … 1Probdotstion
hl7:interpretationCode
CE0 … 1Probdotstion
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.78 ObservationInterpretation (DYNAMIC)