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Template Reaction Observation 2020‑04‑29 12:47:35

Id2.16.756.5.30.1.1.10.4.120
ref
ch-pcc-
Effective Date2020‑04‑29 12:47:35
Statusrejected RejectedVersion Label2016
Namechpcc_entry_ReactionObservationDisplay NameReaction Observation
DescriptionReaction as structured entry
ContextParent nodes of template element with id 2.16.756.5.30.1.1.10.4.120
LabelIHE PCC TF2 Rev.11, 6.3.4.15.10
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
RelationshipSpecialization: template 2.16.756.5.30.1.1.10.4.97 Problem Entry (2016‑11‑12)
ref
ch-pcc-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.5 IHE Problem Entry (DYNAMIC)
ref
ch-pcc-

Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Example
Example
<cda:observation classCode="OBS" moodCode="EVN" negationInd="false">
  <cda:templateId root="2.16.756.5.30.1.1.10.4.120"/>  <cda:templateId root="2.16.756.5.30.1.1.10.4.97"/>  <cda:templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5"/>  <cda:templateId root="2.16.840.1.113883.10.20.1.28"/>  <cda:templateId root="2.16.840.1.113883.10.20.1.54"/>  <cda:id root="1.2.3.999" extension="extension"/>  <cda:code code="" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName=""/>  <cda:text>
    <cda:reference value="#ref"/>  </cda:text>  <cda:statusCode code="completed"/>  <cda:effectiveTime>
    <cda:low value="20200429130414+02:00"/>    <cda:high value="20200429130414+02:00"/>  </cda:effectiveTime>  <cda:value code="" codeSystem="" codeSystemName="" displayName=""/>  <cda:author>
    <!-- template 2.16.756.5.30.1.1.10.9.48 'Author Compilation with name' -->
  </cda:author></cda:observation>
ItemDTCardConfDescriptionLabel
hl7:observation
Problem as structured entry (e.g. syptom, complaint, diagnosis etc.)IHE PCC TF2 Rev.11, 6.3.4.15.10
@classCode
cs1 … 1FOBS
@moodCode
cs1 … 1FEVN
@negationInd
bl1 … 1RThis value remains usually 'false'. If there is an observation that the problem has not occured, this value can be set 'true'. This is a small but important difference to the situation where the problem has not been observed (and therefore no problem has been recorded).
hl7:templateId
II1 … 1MIHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid1 … 1F2.16.756.5.30.1.1.10.4.120
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid1 … 1F2.16.756.5.30.1.1.10.4.97
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.4.5
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid1 … 1F2.16.840.1.113883.10.20.1.28
hl7:templateId
II1 … 1IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid1 … 1F2.16.840.1.113883.10.20.1.54
hl7:id
II1 … *REach adverse reaction SHALL have an identifier.IHE PCC TF2 Rev.11, 6.3.4.15.10
@root
uid1 … 1RMUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.
@extension
st0 … 1 Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:code
CD1 … 1MThe problem type code.IHE PCC TF2 Rev.11, 6.3.4.15.10
@code
cs1 … 1R
@codeSystem
oid1 … 1F2.16.840.1.113883.6.96
@codeSystemName
st1 … 1FSNOMED CT
@displayName
st1 … 1R
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.14 ProblemTypeCode (DYNAMIC)
Included1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:text
ED1 … 1MCDA‑CH V2
hl7:reference
TEL1 … 1MThe reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx']CDA‑CH V2
@value
1 … 1RReference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
 Schematron assertrolered error 
 teststarts-with(@value,'#') 
 MessageThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertrolered error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MessageNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
hl7:statusCode
CS1 … 1M

The statusCode shall be set to 'completed' for all problems.

IHE PCC TF2 Rev.11, 6.3.4.15.10
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)
hl7:effectiveTime
IVL_TS.CH.TZ1 … 1RIndicates the time interval over which the problem is known to be true.IHE PCC TF2 Rev.11, 6.3.4.15.10
hl7:low
TS.CH.TZ1 … 1RPoint of time of the first occurance of the problem.IHE PCC TF2 Rev.11, 6.3.4.15.10
hl7:high
TS.CH.TZ0 … 1CPoint of time when the problem was solved. For all other cases this value remains empty.IHE PCC TF2 Rev.11, 6.3.4.15.10
hl7:value
CD0 … *

This value can be either a coded value or uncoded text. The type is always xsi:type='CD'. For coded values the attributes code, codeSystem, codeSystemName and displayName MUST be present. For uncoded values, the nullFlavor='NAV' attribute and the originalText element MUST be present.

The following value sets are allowed:

  • ICD-10: 2.16.756.5.30.1.126.3.2
  • ICPC-2: 2.16.840.1.113883.6.139
  • SNOMED CT: 2.16.840.1.113883.6.96

The SNOMED CT code 160245001, 'No current problems or disability (situation)' MAY be used to indicate that the patient doesn't currently has any reactions.

For special cases a code from the value set 'Special Case Problems' SHALL be used.

IHE PCC TF2 Rev.11, 6.3.4.15.10
@nullFlavor
st0 … 1FNAV
@code
cs0 … 1 
@codeSystem
oid0 … 1 
@codeSystemName
st0 … 1 
@displayName
st0 … 1 
 CONF
@codeSystem shall be "2.16.756.5.30.1.126.3.2"
or
@codeSystem shall be "2.16.840.1.113883.6.139"
or
@codeSystem shall be "2.16.840.1.113883.6.96"
 Schematron assertrolered error 
 test(@code and @codeSystem) or (@nullFlavor='NAV') 
 MessageEither a code with its code system or nullFlavor='NAV' is required. 
 Schematron assertrolered error 
 testnot(@nullFlavor) or (hl7:originalText) 
 MessageOther problems description MUST be declared in the originalText element in case of nullFlavor. 
Included0 … 1C from 2.16.756.5.30.1.1.10.9.49 Original Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:originalText
ED0 … 1CCDA‑CH V2
hl7:reference
TEL1 … 1MThe reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx']CDA‑CH V2
@value
1 … 1RReference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
 Schematron assertrolered error 
 teststarts-with(@value,'#') 
 MessageThe @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding 'content' element. 
 Variable letNameidvalue 
 Valuesubstring-after(@value,'#') 
 Schematron assertrolered error 
 testancestor::hl7:structuredBody//*[@ID=$idvalue] 
 MessageNo narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>'). 
 Schematron assertrolered error 
 testparent::*/text()=ancestor::hl7:structuredBody//*[@ID=$idvalue]/text() 
 MessageThe originalText content MUST be identical to the narrative text for this reference. 
hl7:author
0 … *This MAY be used to indicate who has documented the observation. This information supersedes any information recorded at higher level.
Contains 2.16.756.5.30.1.1.10.9.48 Author Compilation with name (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.15.10
hl7:entryRelationship
0 … *Antigen doses applicable.
Contains 1.3.6.1.4.1.19376.1.5.3.1.4.12.1 IHE Antigen Dose entry (DYNAMIC)		IHE PCC TF2 Rev.11, 6.3.4.15.10
where [@typeCode='COMP']