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Template Problem Concern 2013‑12‑20

Id1.3.6.1.4.1.19376.1.5.3.1.4.5.2
ref
epsos-
Effective Date2013‑12‑20
Statusdraft DraftVersion Label
NameEntryProblemConcernDisplay NameProblem Concern
Description

This entry is a specialization of the Concern Entry, wherein the subject of the concern is focused on a problem. Elements shown in the example below in gray are explained in the Concern Entry.

Parent Template

The parent of this template is Concern Entry. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.27

This entry has a template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.2, and is a subtype of the Concern Entry, and so must also conform to that specification, with the template identifier of 1.3.6.1.4.1.19376.1.5.3.1.4.5.1. These elements are required and shall be recorded exactly as shown.

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5.2
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Example
Example
<act classCode="ACT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.10.20.1.27"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.1"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>  <id root=" " extension=" "/>  <code nullFlavor="NA"/>  <statusCode code="active|suspended|aborted|completed"/>  <effectiveTime>
    <low value=" "/>    <high value=" "/>  </effectiveTime>  <!-- 1..* entry relationships identifying problems of concern -->
  <entryRelationship type="SUBJ">
    <observation classCode="OBS" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>      <templateId root="2.16.840.1.113883.10.20.1.28"/>      <!-- ... -->
    </observation>  </entryRelationship>  <!-- optional entry relationship providing more information about the concern -->
  <entryRelationship type="REFR"/></act>
ItemDTCardConfDescriptionLabel
hl7:act
REntrdotscern
@classCode
cs1 … 1FACT
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1MEntrdotscern
@root
uid1 … 1F2.16.840.1.113883.10.20.1.27
hl7:templateId
II1 … 1MEntrdotscern
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5.1
hl7:templateId
II1 … 1MEntrdotscern
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5.2
hl7:id
II1 … *REntrdotscern
hl7:code
CD1 … 1RFixed nullFlavor='NA'Entrdotscern
hl7:text
ED0 … 1REntrdotscern
hl7:reference
TEL1 … 1MEntrdotscern
@value
1 … 1RReference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
CS0 … 1ROne of: active|suspended|aborted|completedEntrdotscern
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.777.11.11.2 (DYNAMIC)
hl7:effectiveTime
IVL_TS0 … 1REntrdotscern
hl7:low
1 … 1RThe <low> element shall be present.Entrdotscern
hl7:high
0 … 1CThe <high> element shall be present for concerns in the completed or aborted state, and shall not be present otherwise.Entrdotscern
hl7:entryRelationship
1 … *R

This entry shall contain one or more problem entries that conform to the Problem Entry template 1.3.6.1.4.1.19376.1.5.3.1.4.5. For CDA this SHALL be represented with the <entryRelationship> element. For HL7 Version 3 Messages, this SHALL be represented as a <subjectOf> element. The typeCode SHALL be ‘SUBJ’ and inversionInd SHALL be ‘false’

Note: every Problem Entry used in this section to identify problem of concern MAY have an <entryRelationship> that will indicate the severity of the problem, conforming to the severity entry template (1.3.6.1.4.1.19376.1.5.3.1.4.1). The severity codes to be used are epSOSSeverity, OID 1.3.6.1.4.1.12559.11.10.1.3.1.42.13.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)		Entrdotscern
@typeCode
cs1 … 1FSUBJ
hl7:entryRelationship
0 … *Roptional entry relationship providing more information about the concern. A source of information observation SHALL be the target of an entryRelationship whose value for “entryRelationship / @typeCode” SHALL be “REFR” “Refers to” 2.16.840.1.113883.5.1002 ActRelationshipType STATIC. A source of information observation SHALL be represented with Observation.CONF‑524 / CONF‑525
@typeCode
cs1 … 1FREFR
hl7:observation
ASTM CCR requires that all data objects have a stated source (or state explicitly that the source is unknown) so that any data within the summary can be validated. The source of data may be a person, organization, reference to some other data object, etc.CONF‑524 / CONF‑525
@classCode
cs0 … 1FOBSCONF‑526
 The value for “Observation / @classCode” in a source of information observation SHALL be “OBS” 2.16.840.1.113883.5.6 ActClass STATIC.
@moodCode
cs0 … 1FEVNCONF‑527
 The value for “Observation / @moodCode” in a source of information observation SHALL be “EVN” 2.16.840.1.113883.5.1001 ActMood STATIC.
hl7:code
CD1 … 1RA source of information observation SHALL contain exactly one Observation / code. The value for “Observation / code” in a source of information observation SHALL be “48766-0” “Information source” 2.16.840.1.113883.6.1 LOINC STATIC.CONF‑530 / CONF‑531
@code
CONF0 … 1F48766-0
@codeSystem
0 … 1F2.16.840.1.113883.6.1
@displayName
0 … 1FInformation source
hl7:statusCode
1 … 1RA source of information observation SHALL contain exactly one Observation / statusCode. The value for “Observation / statusCode” in a source of information observation SHALL be “completed” 2.16.840.1.113883.5.14 ActStatus STATIC.CONF‑528 / CONF‑529
@code
CONF0 … 1Fcompleted
hl7:value
1 … 1MA source of information observation SHALL contain exactly one Observation / value. The absence of a known source of information SHALL be explicity asserted by valuing Observation / value in a source of information observation with the text string “Unknown”.CONF‑532 / CONF‑533