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Template IHE Problem Status Observation 2019‑10‑16 17:29:32

Id1.3.6.1.4.1.19376.1.5.3.1.4.1.1
ref
ch-pcc-
Effective Date2019‑10‑16 17:29:32
Statusdraft DraftVersion Label2014
NameIHEProblemStatusObservationDisplay NameIHE Problem Status Observation
Description

Any problem or allergy observation may reference a problem status observation. This structure is included in the target observation using the <entryRelationship> element defined in the CDA Schema. The clinical status observation records information about the current status of the problem or allergy, for example, whether it is active, in remission, resolved, et cetera. The example below shows the recording of clinical status of a condition or allergy, and is used as the context for the following sections.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.1.1
Label6.3.4.4
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipVersion: template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 (2013‑12‑20)
ref
ch-pcc-

Specialization: template 2.16.840.1.113883.10.20.1.50 (DYNAMIC)
ref
ch-pcc-

Specialization: template 2.16.840.1.113883.10.20.1.57 (DYNAMIC)
ref
ch-pcc-
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.57"/>  <templateId root="2.16.840.1.113883.10.20.1.50"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.1.1"/>  <code code="33999-4" displayName="Status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>  <text>
    <reference value="#cstatus-2"/>  </text>  <statusCode code="completed"/>  <value xsi:type="CE" code=" " codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"/></observation>
ItemDTCardConfDescriptionLabel
hl7:observation
6.3.4.4
hl7:templateId
II1 … 1M6.3.4.4
@root
uid1 … 1F2.16.840.1.113883.10.20.1.57
hl7:templateId
II1 … 1M6.3.4.4
@root
uid1 … 1F2.16.840.1.113883.10.20.1.50
hl7:templateId
II1 … 1M6.3.4.4
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.1.1
hl7:code
CD1 … 1M

This observation is of clinical status, as indicated by the <code> element. This element must be present.

6.3.4.4
@code
CONF1 … 1F33999-4
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1FStatus
hl7:text
ED1 … 1M

The <text> element is required and points to the text describing the problem being recorded; including any dates, comments, et cetera. The <reference> contains a URI in value attribute. This URI points to the free text description of the problem in the document that is being described.

6.3.4.4
hl7:reference
TEL1 … 1M6.3.4.4
hl7:statusCode
CS1 … 1R

The code attribute of <statusCode> for all clinical status observations shall be completed. While the <statusCode> element is required in all acts to record the status of the act, the only sensible value of this element in this context is completed.

6.3.4.4
@code
CONF0 … 1Fcompleted
@codeSystem
0 … 1F2.16.840.1.113883.5.14
hl7:value
CE1 … 1MThe element contains the clinical status. It is always represented using the CE datatype (xsi:type='CE'). It shall contain a code from the following set of values from SNOMED CT.6.3.4.4