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Template IHE Problem Entry 2016‑09‑26 09:50:55

Id1.3.6.1.4.1.19376.1.5.3.1.4.5
ref
IHE-PCC-
Effective Date2016‑09‑26 09:50:55
Statusactive ActiveVersion Label2014
NameIHEProblemEntryDisplay NameIHE Problem Entry
Description

This section makes use of the linking, severity, clinical status and comment content specifications defined elsewhere in the technical framework. In HL7 RIM parlance, observations about a problem, complaint, symptom, finding, diagnosis, or functional limitation of a patient is the event (moodCode='EVN') of observing (<observation classCode='OBS'>) that problem. The <value> of the observation comes from a controlled vocabulary representing such things. The <code> contained within the <observation> describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.

Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.28

ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.5
Label6.3.4.14
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 0 templates, Uses 3 templates
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.4.1Containmentpending IHE Severity Entry (2016)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.1Containmentactive IHE Problem Status Observation (2014)DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.4.1.2Containmentactive IHE Health Status Observation (2014)DYNAMIC
RelationshipSpecialization: template 2.16.840.1.113883.10.20.1.28 Problem observation (DYNAMIC)
ref
ccd1-
ItemDTCardConfDescriptionLabel
hl7:observation
R

The basic pattern for reporting a problem uses the CDA <observation> element, setting the classCode='OBS' to represent that this is an observation of a problem, and the moodCode='EVN', to represent that this is an observation that has in fact taken place. The negationInd attribute, if true, specifies that the problem indicated was observed to not have occurred (which is subtly but importantly different from having not been observed).

The value of negationInd should not normally be set to true. Instead, to record that there is "no prior history of chicken pox", one would use a coded value indicated exactly that. However, it is not always possible to record problems in this manner, especially if using a controlled vocabulary that does not supply pre-coordinated negations, or which do not allow the negation to be recorded with post-coordinated coded terminology.

6.3.4.14
@moodCode
cs1 … 1FEVN
hl7:templateId
II1 … 1R6.3.4.14
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II1 … 1R6.3.4.14
@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
hl7:id
II1 … 1M6.3.4.14
hl7:code
CD1 … 1R6.3.4.14
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
6.3.4.14
hl7:statusCode
CS0 … 1R

A clinical document normally records only those condition observation events that have been completed, not observations that are in any other state. Therefore, the <statusCode> shall always have code='completed'.

6.3.4.14
@code
CONF0 … 1Fcompleted
hl7:effectiveTime
IVL_TS0 … 1R6.3.4.14
hl7:value
CD1 … *R6.3.4.14
hl7:originalText
0 … 1R

The <originalText> element within the <code> element described above is used as follows: the <value> contains a <reference> to the <originalText> in order to link the coded value to the problem narrative text (minus 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.

6.3.4.14
hl7:reference
0 … 1R6.3.4.14
hl7:entryRelationship
0 … 1R
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 IHE Severity Entry (DYNAMIC)
6.3.4.14
hl7:entryRelationship
0 … 1R



Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 IHE Problem Status Observation (DYNAMIC)
6.3.4.14
@typeCode
cs1 … 1FREFR
hl7:entryRelationship
0 … 1R
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 IHE Health Status Observation (DYNAMIC)
6.3.4.14
@typeCode
cs1 … 1FREFR