Id 2.16.756.5.30.1.1.10.4.106 Effective Date 2017‑09‑15 08:59:41 Status Version Label 2018 Name cdachsmcp_entry_ProblemEntry Display Name 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 () that problem. The of the observation comes from a controlled vocabulary representing such things. The contained within the describes the method of determination from yet another controlled vocabulary. An example appears below in the figure below.
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.106 Label CDA‑CH‑SMCP Classification CDA Entry Level Template Open/Closed Open (other than defined elements are allowed) Used by / Uses Used by 0 transactions and 1 template, Uses 4 templates
Relationship Specialization: template 2.16.756.5.30.1.1.10.4.97 Problem Entry (DYNAMIC) ref
ch-pcc-
IHE Problem Entry (2016‑09‑26 09:50:55) ref
IHE-PCC-
Problem observation (DYNAMIC) ref
ccd1-
Example Example < observation classCode =" OBS " moodCode =" EVN " negationInd =" false " > < templateId root =" 2.16.756.5.30.1.1.10.4.106 " / > < templateId root =" 2.16.756.5.30.1.1.10.4.97 " / > < 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 " / > < id root =" BAA96E2C-BF1F-4018-AC23-24AE06CE9E38 " / > < code code =" 282291009 " codeSystem =" 2.16.840.1.113883.6.96 " codeSystemName =" SNOMED CT " displayName =" Problem " / > < text > < reference value =" #your_content_id " / > </ text > < statusCode code =" completed " / > < effectiveTime > < low value =" 20120801 " / > < high nullFlavor =" UNK " / > </ effectiveTime > < value xsi:type =" CD " code =" N18.9 " codeSystem =" 2.16.756.5.30.1.126.3.2 " codeSystemName =" ICD-10 " displayName =" Chronic kidney disease, unspecified " > < originalText > < reference value =" #your_content_id " / > </ originalText > </ value > < entryRelationship typeCode =" SUBJ " > <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.1 'IHE Severity Entry' --> </ entryRelationship > < entryRelationship typeCode =" REFR " > <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 'IHE Problem Status Observation' --> </ entryRelationship > < entryRelationship typeCode =" REFR " > <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 'IHE Health Status Observation' --> </ entryRelationship > < entryRelationship typeCode =" SUBJ " > <!-- template 1.3.6.1.4.1.19376.1.5.3.1.4.2 'IHE Comment Entry' --> </ entryRelationship > </ observation >
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Item DT Card Conf Description Label hl7:observation R CDA‑ @classCode cs 1 … 1 F OBS @moodCode cs 1 … 1 F EVN @negationInd cs 1 … 1 R CONF @negationInd shall be "false" or @negationInd shall be "true"
hl7:templateId II 1 … 1 M CDA‑ @root uid 1 … 1 F 2.16.756.5.30.1.1.10.4.106 hl7:templateId II 1 … 1 M CDA‑ @root uid 1 … 1 F 2.16.756.5.30.1.1.10.4.97 hl7:templateId II 1 … 1 R CDA‑ @root uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.5 hl7:templateId II 1 … 1 R CDA‑ @root uid 1 … 1 F 2.16.840.1.113883.10.20.1.28 hl7:id II 1 … 1 M CDA‑ hl7:code CD 1 … 1 R CDA‑ @displayName st 0 … 1 @codeSystemName st 0 … 1 @codeSystem oid 0 … 1 @code cs 0 … 1 @nullFlavor cs 0 … 1 Schematron assert role test (@displayName and @codeSystem and @codeSystemName and @code) or (@nullFlavor) Message Either a code with its attributes @displayName, @codeSystem, @codeSystemName and @code or a nullFlavor is required. hl7:text ED 1 … 1 R CDA‑ hl7:reference TEL 0 … 1 CDA‑ @value st 1 … 1 R hl7:statusCode CS 1 … 1 M CDA‑ @code CONF 1 … 1 F completed hl7:effectiveTime IVL_TS 0 … 1 R CDA‑ hl7:low IVXB_TS CDA‑ hl7:high IVXB_TS CDA‑ hl7:value CD 1 … * R CDA‑ hl7:originalText 1 … 1 R CDA‑ hl7:reference 0 … 1 R CDA‑ @value st 1 … 1 R hl7:entryRelationship 0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1 IHE Severity Entry (DYNAMIC) CDA‑ @typeCode cs 1 … 1 F SUBJ hl7:entryRelationship 0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.1 IHE Problem Status Observation (DYNAMIC) CDA‑ @typeCode cs 1 … 1 F REFR hl7:entryRelationship 0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.4.1.2 IHE Health Status Observation (DYNAMIC) CDA‑ @typeCode cs 1 … 1 F REFR hl7:entryRelationship 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.4.2 IHE Comment Entry (DYNAMIC) CDA‑ @typeCode cs 1 … 1 F SUBJ
Draft
IHE Severity Entry (2016)
IHE Problem Status Observation (2014)
SMCP
error